Microsoft Word - Health Statement rev 20170315 Haley …
Physicians Statement (to be completed by Physician/NP/PA)Employee/Patient Name: Date of Birth: To the best of my knowledge, the above patient is in good physical health, free from back injury, free from communicable disease, able to perform routine clinical duties. Patient/Employee is free from any work restrictions. I have examined the above-mentioned person within the last 12 months. Date of Last Examination _____/______/_____.Additional Comments:_______________________________________________________Physician Name (please print): Physician’s Address: City: State: Zip: Office Phone Number: ***Physician’s (MD/NP/PA) Signature: Office Stamp9270 Junction Rd Suite A, Frankenmuth, MI 48734 PHONE: 989-607-9329 FAX: 877-652-5053 ................
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