Physician s Statement & Medical Clearance Form - valleymed 2025

1. Click ‘Get Form’ to open the Physician’s Statement & Medical Clearance Form in the editor.
2. Begin by entering your personal information, including your Name, Date of Birth, and Today’s Date in the designated fields.
3. Next, provide your Physician’s Name, Phone Number, and Fax Number. Ensure these details are accurate for effective communication.
4. In the permission section, check the box to authorize your physician to release pertinent medical information. This ensures confidentiality while facilitating your fitness journey.
5. Sign and date the form at the bottom to confirm your consent. This step is crucial for processing your medical clearance.
6. For medical staff use only: The physician will check one of the statements regarding fitness participation and provide any necessary restrictions or reasons if applicable.

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