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.



Please type your First and Last Name





Your patient: _____________________________________________________
(fill in name) is beginning a health and wellness program with Satin Wellness In Home Personal Training.

  • 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.

_____________________________________________________
_________________________



Steve Satin, President and Founder

Satin Wellness, Inc.

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