What does the Physical Examination Consent Form Template consist of?
A Physical Examination Consent Form Template includes personal information of the individual, a clear description of the examination, an explanation of its purpose, potential risks, a consent statement, and a space for the individual’s signature and date. It is a concise document ensuring that the individual gives informed consent for the specified physical examination.
Template
[Your Company’s Logo or Letterhead]
Candidate’s Name: [Candidate’s Name]
Date of Birth: [Candidate’s Date of Birth]
Position Applied For: [Job Title]
Date of Examination: [Date]
Physical Examination Consent Form
I, [Candidate’s Name], authorize [Your Company’s Name] to conduct a physical examination during the pre-employment screening. I understand that this examination is intended to assess my overall health and physical fitness to perform the duties of the position I have applied for.
I consent to the following:
- Examination Procedures: I understand that the physical examination may include, but is not limited to, the following procedures: general medical history review, blood pressure measurement, vision and hearing tests, range of motion assessment, cardiovascular assessment, and any other relevant assessments as determined by the examining healthcare professional.
- Medical Records Release: I authorize the release of any medical records or information related to this physical examination to the designated healthcare professional conducting the examination. This release is strictly limited to assessing my fitness for employment.
- Confidentiality: I acknowledge that the information obtained during the physical examination will be treated as confidential and will only be disclosed to authorized personnel to evaluate my candidacy. All medical records and information will be handled in compliance with applicable privacy laws and regulations.
- Results and Recommendations: I understand that the healthcare professional conducting the examination may provide a report summarizing the findings and any recommendations related to my fitness for the position. This report may be shared with the appropriate personnel within [Your Company’s Name] involved in the hiring process.
- Responsibility for Costs: I understand that any costs associated with the physical examination, including medical tests or consultations, are my responsibility and will not be reimbursed by [Your Company’s Name].
- Compliance with Company Policies: I agree to comply with any additional policies and requirements set forth by [Your Company’s Name] regarding pre-employment physical examinations.
I acknowledge that participation in the physical examination is voluntary, and I understand that I may withdraw my consent at any time by notifying [Your Company’s Name] in writing.
By signing below, I confirm that I have read and understood the terms of this Physical Examination Consent Form and voluntarily provide my consent to undergo the physical examination described herein.
Candidate’s Signature: [Candidate’s Signature]
Date: [Date]
Witness (Company Representative): [Company Representative]
Signature: [Signature ]
Date: [Date]