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-- Print This Form for Your Doctor to Complete --
Date _________________
Dear Doctor:
Your patient ___________________________ wishes to exercise with the Iverson Mallwalkers program. The activity, sponsored by Iverson Mall, will involve the following:
Self-paced walking 3 times a week, within Iverson Mall.
Warm-up and cool down strongly encouraged.
Please identify below any recommendations or restrictions that are appropriate for your patient in this exercise program. Also, if your patient is taking medications that will affect his or her heart rate response to exercise, please indicate the manner of the effect (raises, lowers or has no effect on heart rate response.)
Please have your patient bring this form to Iverson Mall at time of registration. Feel free to contact me (301/423-8430) if you require further information.
Jeannette L. Kainu
Marketing Director
Iverson Mall
____________________________ has my approval to exercise in the Iverson Mallwalker program.
Restrictions ___________________________________________________________
Medication/Purpose _____________________________________________________
Effect ________________________________________________________________
Physician __________________________ Phone# ___________________________
Signature __________________________ Date _____________________________
A project of Iverson Mall