PHYSICIAN’S STATEMENT Statement of Health
PHYSICIAN'S STATEMENT
Employee/Applicant
Name: ______________________________________________________________ DOB: ______________________________________________________________
Statement of Health
To be completed by Physician
I have examined the individual named above and to the best of my knowledge; he/she is in good physical and mental health, free of any communicable diseases and is able to function in his/her profession at full capacity. By signing below I certify that the above information is true.
Name (printed): ______________________________________________________
Signature:
______________________________________________________
Office Phone Number: ________________________________________________
Date of Exam: _____________________________________________________ Office Stamp (if available)
Office Address:
Revised 4-11-14
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