Kentucky Pediatric Society

AGREEMENT AND ORDER FORM

I agree to the following terms of the Walking Works program sponsored by the Kentucky Chapter of the American Academy of Pediatrics and anthem Blue Cross and Blue Shield

The program can be offered to all patients 11 years of age or older, who have a BMI in the At-Risk or Obese category.

I will have the patient and their parent or guardian sign the Walking Works pledge at the bottom of the Walking Log.

I will schedule the patient for a return visit within 60 to 90 days to review the log and assess progress.

Please send the requested number of Walking Works packets, including literature and pedometers to the office address listed below. (Maximum initial order is 25 sets)

Number of packets:
Physician or practice Name:
Street Address:

City, State and Zip:

Email Address:

Please allow 15 days for delivery