Patient Referral Form

Referring Provider Information

Provider Name*

Practice / Clinic*

Phone Number

Email Address*

Patient Full Name*

Patient Phone Number*

Patient Email Address

These are used only to contact the patient regarding this referral.

Primary Reason for Referral*

Chronic condition management

Post-rehabilitation / return to activity

Balance or mobility support

General fitness with medical considerations

Other

Additional Notes (optional)

Has the patient been cleared for exercise or supervised physical activity?*

Yes — cleared without restrictions

Yes — cleared with considerations (noted below)

Clearance pending / please coordinate first

Unknown

Clearance Notes (optional)

Detailed medical documentation is not required at this stage.

I confirm the patient is aware of and has consented to this referral.

Please contact our office before reaching out to the patient.

Exercise Physiology-Based In-Home Training

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Houston, TX

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