02 PHYSICIAN INFORMATION FORM

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MEDICALLY DIRECTED PROGRAMS

PHYSICIAN INFORMATION FORM

Date:

COMMUNICATION AUTHORIZATIONION

While I am participating in a Medically Directed Exercise program, I understand that at least once per week metrics (measurements, including heart rate, blood pressure, body weight, blood oxygen, and others) to track my progress will be measured. I also understand that the typical length of these programs is twleve (12) weeks.

At the end of each 12-week cycle, a summary report of my metrics will be created. In addition, the raw data will be retained anonomously (identified by a code #, not my name) by Parks & Rec Rx Group for various analytics,

I hereby authorize Parks & Rec Rx Group and the Facility named above to digitally forward my Post-Program Summary to the Physician indicated above.