Doctor Waiver Once you've completed the information on the Doctor Waiver, it will be printed and mailed to your Physician. Your physician will complete and sign the waiver. Once completed, all of your physical information is validated and up to date. The more information we have about your physical health, the better and more comprehensive your program. Client Electronic Signature: Please type your First and Last Name I understand that checking this box constitutes a legal signature. Date: Dear Dr.: , Your patient: _____________________________________________________ (fill in name) is beginning a health and wellness program with Satin Wellness In Home Personal Training. Their activities will involve some or all of the following controlled, supervised and monitored exercises: Cardiovascular exercise (i.e. treadmill, exercise bicycle, stair climber, elliptical, walking or running) Strength training with hand weights/resistance tubes/ankle weights - trainer assisted Abdominal exercises with supported cervical/lumbar spine Other: _____________________________________________________ If your patient is taking any MEDICATIONS that could/will affect his/her heart rate or response to any exercise, please list below and indicate the effect. Medication(s): _____________________________________________________ Effect (i.e.: HR, HR): _____________________________________________________ Please identify any recommendations or restrictions that are appropriate for your patient in an exercise program:________________________________________________________________________________________ ___________________________________ has my approval to begin/ continued an exercise program with recommendations or restrictions stated above. Physician Signature : _____________________________________________________ Date: _________________________ Steve Satin, President and Founder Satin Wellness, Inc.