KP Total Estate — Medical Clearance Form

KP Total Estate Health & Fitness Services

Medical Clearance Form

Form Ref: KPTE-MC-2026

To the Healthcare Provider: The individual named below has enrolled in a fitness and wellness coaching programme with KP Total Estate. Based on their health intake responses, medical clearance has been recommended before they begin physical activity. Please review their health history and complete this form to indicate whether they are cleared to participate.

Client Information

Client Full Name

Date of Birth

Phone

Programme Description

The client will be participating in a virtual fitness coaching programme that may include:

Strength and resistance training (bodyweight, bands, and/or weights)
Cardiovascular conditioning (walking, low-to-moderate intensity)
Flexibility and mobility work
Nutrition coaching and dietary guidance

All sessions are conducted virtually and adapted to the individual's fitness level and medical considerations. The programme is supervised by a NASM-Certified Personal Trainer and NASM-Certified Nutrition Coach.

Clearance Decision

Please indicate your recommendation for this patient (check one):

Cleared without restriction — This patient is cleared to participate in the physical activity programme described above without limitations.

Cleared with restrictions — This patient is cleared to participate with the following modifications or limitations:

Restrictions / Modifications (if applicable)

Not cleared — This patient is not cleared to participate in a physical activity programme at this time. Reason:

Reason (if not cleared)

Healthcare Provider Information & Signature

Provider Name (Print)

Title / Credentials

Practice / Facility Name

Phone

Provider Signature

Date

Return this completed form to:

Kristie Perry — KP Total Estate

Email: kptotalestate@gmail.com | Phone: (713) 205-3239

You may scan/photograph this form and email it, or have your provider fax or send it directly. Kristie will confirm receipt.