Refer a patient for exercise

Physicians who are registered with Sunflower Wellness can use this page to refer a patient online for exercise. Please fill in all fields in the form below and press the "Send" button at the end.

You will need to register with Sunflower Wellness to refer patients, if you have not already done so.

If you wish, you can order duplicate-copy Medical Clearance paper forms instead.

Physician name* :
Physician e-mail* :
Physician phone: (Include area code)
Patient's name* :
Patient's e-mail* :
Patient's phone* : (Include area code)
Diagnosis:
Treatment / Medications:
Lymphedema / Restrictions:
Cancer-related Pain / Restrictions:
As a participant of IMPACT, each patient will receive an individually designed exercise program. The components of each program design are cardiovascular, flexibility, range of motion, stabilization, total body functional movements, resistance training and relaxation techniques. The patient will be instructed and monitored by a professional certified trainer while in the IMPACT program.
Physical Activity / Program Recommendations Please indicate activity limitations below and enter comments as needed.
Unrestricted activity Activity restricted / limited to:	Enter any limitations here.
Special Concerns / Additional Comments:
Please consider this patient for an IMPACT program scholarship for exercise.