Victoria Wellness Professionals - Documents & Forms

Date: ________________________

Dear Doctor,

Your patient, ______________________________ , wishes to start a personalized training program. The activity will involve the following:

If your patient is taking medications that will affect their response to exercise, please indicate below the medications and manner of their effect:

_________________________________________________________________________

Please identify any recommendations or restrictions that are appropriate for your patient in this exercise program:

_________________________________________________________________________

Thank you,

Narina Prokosch, R.N.
Victoria Wellness Professionals

Physician completes:

____________________________________ has my approval to begin an exercise program with the recommendations or restrictions stated above.

Signed: _____________________________________

Date: ______________________________ Phone: ________________________