Medical Release Form

Dear  Dr. _______________________:

Your patient ____________________________________ (patient name) wishes to partcipate in a physical activity and training program. Your patient's current goals and proposed physical activity plan are as follows (to be completed by patient):

_________________________________________________________________________

_________________________________________________________________________


Please list any restrictions that you would recommend for this program (to be completed by physician):

Physical limitations: ________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Medications: _______________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Other restrictions: __________________________________________________________

__________________________________________________________________________

__________________________________________________________________________


__________________________________(patient name) has my approval to participate in this physical activity and training program with the restrictions described above.


Physician Signature __________________________________ Date: _______________

Participant - Please return this completed form to:  Terry Gupta, MSW, E-RYT
                                                                                                   YogaCaps, Inc.
                                                                                                   5 Jason Drive, Merrimack, NH 03054