Medical Exercise Forms

Client Name *

First Name

Last Name

BY CHECKING THE BOX BELOW, I HEREBY AUTHORIZE RELEASE OF INFORMATION TO SHERYL TEITELBAUM. Please furnish to Sheryl Teitelbaum (hereinafter facility noted in form and/or any of its personnel), information, copies of any and all hospital and medical records or reports of any sort, charts, notes, x-rays, lab reports and prescription information, including the right to inspect and copy such records. Facility is to be furnished any and all other information without limitation pertaining to any confinement, examination, treatment or condition of myself, including medical, dental, psychological or other treatment, examinations, or counseling for any condition, medical, dental or psychological. This AUTHORIZATION shall be considered as continuing and you may rely upon it in all respects unless you have previously been advised by me in writing to the contrary. It is expressly understood by the undersigned and you are hereby authorized with the same validity as though an original had been presented to you. *

Release of Information

Confirmed

Client Name *

First Name

Last Name

BY CHECKING THE BOX BELOW, I HEREBY CONFIRM: In consideration of being allowed to participate in the activities and programs with Sheryl Teitelbaum and to use related facilities or gyms, equipment and machinery in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge and its directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities or my use of equipment or machinery in the above mentioned activities. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities or the use of any equipment at Living4Health at 3 Oxford Lane, Middletown, NJ 07748. *

Release of Liability

Confirmed

BY CHECKING THE BOX BELOW, I HEAREBY CONFIRM: I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment is a potentially hazardous activity. I also understand that fitness activities involve the risk of injury and even death, and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I understand this program does not provide any form of medical treatment, nor are its fitness professionals, licensed medical practitioners. I hereby agree to expressly assume and accept any and all risks of injury or death. *

Confirmed