(Proudly Physician-Owned)
14701 N. Kelly Ave, Edmond, Oklahoma · (405) 752-1233
Patient Name:
________ Date:
________
Diagnosis (please check all that apply):
 Diabetes, Type II
 Diabetes, Type I
 Metabolic Syndrome
 Obesity/Overweight
 HTN
 CHF
 CAD
 PVD
 Atrial Fibrillation
 Hyperlipidemia
 History CAD
 History of MI
 Osteoporosis
 DJD specify _________
 Sedentary Life
 Other (please specify):
 Other (please specify):
Services Ordered:
 Exercise-Readiness Assessment
 Fit3D body scan
 Fitness reassessment
 VO2 submax
 Resting Metabolic Rate
 Personal Training
Physician-Clinic Name_____________________________
Address_________________
Phone#_________________
Fax#_______________
I hereby certify the above services have been deemed medically necessary.
(Physician Signature)
14701 N. Kelly  Edmond, OK 73013  405.752.1233
www.KeyHealthInstitute.com
Key Health Institute
(Proudly Physician-Owned)
14701 N. Kelly Ave, Edmond, Oklahoma · (405) 936-8720
Please note: The Key Health facility is located on Kelly between Memorial road and
33rd street on the west side of the street just north of Arctic ice skating rink.
14701 N. Kelly  Edmond, OK 73013  405.752.1233
www.KeyHealthInstitute.com