Physician Medical Clearance — Hastings Fitness and Nutrition

Physician Medical Clearance — Hastings Fitness and Nutrition

CONFIDENTIAL: Complete your section to help Hastings Fitness and Nutrition design a safe exercise program.
Part 1 — Coach referral
Client full name

First NameMiddle NameLast Name
Client email
example@example.com
Date of referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for referral
Coach name
Coach signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part 2 — Client information
Client: complete this section and sign. Then forward the email you received (or this link) to your physician so they can complete Part 3. Earlier sections are locked.
Full name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency contact name and phone
Primary physician name
Physician email (optional)
example@example.com
Authorization to release medical information

I, {q11_fullname9}, authorize my physician, {q16_textbox14}, and their practice to complete Part 3 of this form and release it to Hastings Fitness and Nutrition and its coach.

What may be released: only the information asked for in Part 3: my clearance level, exercise restrictions and limits, the conditions and medications that matter for exercise, warning signs, and my physician's contact details. This does not authorize release of my full medical record, psychotherapy notes, or records of substance use treatment, HIV testing or mental health treatment.

Purpose: at my request, so my coach can design and adjust a safe exercise program.

Expiration: this authorization expires 12 months after I sign it, unless I revoke it sooner.

My rights:
- I can revoke this at any time by telling my physician's office in writing and emailing hastingsfitness23@gmail.com. Revoking doesn't undo anything already released.
- My physician can't make my treatment, payment or insurance eligibility depend on whether I sign. Hastings Fitness and Nutrition does require a completed clearance before training starts.
- Hastings Fitness and Nutrition isn't a healthcare provider, so once this information is released it may no longer be protected by HIPAA. Hastings Fitness and Nutrition agrees to use it only to plan my training, never to sell or share it, to keep it in a secured account, and to delete it if I ask after coaching ends.
- I'll get a copy of this signed form by email.
I agree to sign electronically. My electronic signature counts the same as a handwritten one.
Signing for someone else? Your name and relationship
Parent, guardian or legal representative only. Leave blank if you are the client.
Agreement
Client signature
Done? Please forward this form link to your physician now. Your training starts once your coach receives the completed clearance.
Date (client)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician: please complete and sign this section. Parts 1 and 2 are locked for your reference.

The patient's signed authorization in Part 2 permits release of this information.
Part 3 — Physician clearance
Proposed exercise program
Clearance level
Condition(s) relevant to exercise
Restrictions
Maximum load
Range of motion limit
Other restriction
Maximum heart rate (bpm)
Maximum RPE (1–10)
No exercise if blood pressure is above
Maximum session length (minutes)
Medications that affect heart rate, blood pressure, or blood sugar
Warning signs to stop exercise
Comments
Physician name
Credentials
Practice name
License number
Practice address
Physician phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax or email
Re-evaluate by

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician signature
Date signed (physician)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office stamp

Cancelof
Should be Empty:

Physician Medical Clearance — Hastings Fitness and Nutrition

Part 1 — Coach referral

Part 2 — Client information

Part 3 — Physician clearance