Electronic Medical Release Waiver

ThinU Body Contouring

4075 Old Milton Parkway, Suite 4, Alpharetta, GA 30005

Medical Clearance Form For participation in a Korr Medical Metabolic VO2 System Assessment

Dear Doctor:

During the intake process at the ThinU Body Contouring Center, your patient completed a Participant Activity Readiness Questionnaire Form. Information on this form indicates your patient will require a physician’s clearance form. The patient has indicated the following health risk(s):

List Your Health Risk(s) Here: * Please enter your answer here.

Patient Name: * Please enter your name.

The patient’s VO2 Metabolic Exercise Assessment will take place at the ThinU Body Contouring Center located at 4075 Old Milton Parkway, Suite 4, Alpharetta, GA. 30005 and will be administered by personnel trained in use of Korr Medical Systems Metabolic Testing Systems. If you know of any medical, or other reasons why your patient should not undergo a VO2 exercise Metabolic Assessment at the ThinU Body Contouring Center, please indicate this on this form. By completing the form below you are not assuming any responsibility for our administration of the VO2 Exercise Metabolic Assessment.

PHYSICIAN REPORT

Please check one: *

I know of no reason why the applicant may not participate.

I believe the applicant can participate but I urge caution because (please list limitations below)

The applicant should not engage in the activities (Please list activities below):

I recommend that the participant NOT participate.

Please select at least one choice above.

Participant limitations or restricted activities (If any): Please enter your answer here.

Information other than what is requested is also greatly appreciated. Thank you in advance for your recommendations and support of this individual: Please enter your answer here.

Your signature *

Click to sign

Please sign here.

Please Enter Date *

Please enter valid date.

Please fill in Address: *

Please enter address.

Phone number: * Please enter your phone number.

Please return Medical Clearance Form to:

ThinU Body Contouring Center

4075 Old Milton Parkway, Suite 4, Alpharetta, GA. 30005

Phone 678-996-1313

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