SHASHIDO ENTERPRISES
Return to class
Medical Clearance Form
CLIENT’S NAME:___________________________________________________________________
Contact Phone:____________________________________________________________________
Condition / Injury that prevented attendance at class:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___ I believe my client can safely return to a progressive physical activity program. (tick if true)
___ I believe my patient can participate, but I urge caution because of the following limitations:
_______________________________________________________________________________
_______________________________________________________________________________
___ My patient should not engage in the following specific exercise/s:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Providers Name:_____________________________________Phone:_________________________
Address:_________________________________________________________________________
Providers Signature:__________________________________Date:__________________________
If you have any questions about the program, please do not hesitate to call Shashido Enterprises owner, Shane Shiels on 0420 347 550
