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Template: Medical Intake

Consent for Medical Examination Form for Employee Form Template

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Collect consent from employees before a medical examination for occupational purposes.

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Full Name of Employee *

Date of Birth *

Position/Job Title

Date of Examination *

Purpose of Examination *

Medical Provider/Clinic Name *

Do you understand and agree to the above consent statement? *

Additional Comments or Questions

Signature of Employee *

Date of Consent *

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