Physician's Statement Form

* Required Information

PERSONAL DATA

Name *

Social Security Number *

Address *

City *

State *

Zip *

Phone *

Cell *

MEDICAL RELEASE AUTHORIZATION

I, do hereby authorize to release any information acquired during medical examination, relevant to employment with Kindhearted Healthcare Services.

Immunization Records – Kindhearted Healthcare Services must receive a copy of the results of all vaccinations, and or chest x-ray reports (if applicable) before employee is hired for Private Duty Nursing Services. Vaccination dates, not titers, are required for Private Duty Nursing Services only.

	Date	Results	Immune
Hepatitis Vaccine 1
Hepatitis Vaccine 2
Hepatitis Vaccine 3
Polio Vaccine
MMR Vaccine
Diphtheria-Tetanus (DT) Vaccine
T.B. Skin Test (PPD)
Chest X-ray (only if PPD pos.)
BCG Vaccine
(vaccine given in foreign countries for TB, not given in USA)

Physical Examination

Temp

Pulse

Respirations

Blood Pressure

The above-named patient has been examined by me and found to be in good physical and mental health, free of communicable disease and able to function without any physical limitations or weight lifting restrictions as a healthcare professional.

Physician Name (please print)

License Number

Physician Address

City

State

Zip

Physician Signature *

Clear

Date

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.