Medical Clearance & Permission Form
For the Healthy Futures Eating Disorder Intensive Outpatient Program (EDIOP)
I certify that _________________________________(patient name) is in good medical standing to participate in an outpatient eating disorder program one or two days per week, three hours each day and does not require further medical treatment that would preclude participation (tube feeding, rehydration, I. V.’s to balance electrolytes, etc.)
_________Date of most recent office visit
_________Date of most recent labs, if done
_____normal or _____abnormal (what levels)_________________________
If abnormal, how is it being treated?___________________________
_________Date of most recent EKG, if done
Any
restrictions/suggestions that you would recommend (diet, exercise,
work)?_________________________________________________
I
am available to consult with if needed at ___________________(phone #).
I
plan on following this patient on a regular basis as needed.
YES NO
_______________________________________________________
Signature
Print
Name
Practice Address & Phone
__________________________________
___________________________________
___________________________________
Please fax to: Healthy Futures, 480-
For
further questions or information, contact
Mia S. Elwood, LCSW (program director)
Phone: 480-451-8500
E-mail: HealthyFuturesAZ@cox.net
Online:
www.healthy-futures.com