Fill and Sign the Background Check Physical Exam Consent Authorization Form

Physical Examination Consent Form I, _____________________, voluntarily consent to a medical examination paid for by and conducted at the request of _____________________ (hereinafter “the company"). I understand that I will receive a copy of the written medical evaluati on of my ability to physically perform essential job functions. Additionally, I will be offere d the opportunity to provide additional responsive information to any aspects of the examination I feel are incomplete or incorrect. I acknowledge that I have had the opportunity to ask questions about this medical examination, and that these questions have been completely and satisfactorily answered. I understand that I am allowed to ask questions of the examining physician concerning any portion of the examination and that I may stop the examination at any time. However, I acknowledge that if I do not complete the examination, I must provide an explanation the company and that thi s may result in the job offer being withdrawn. I hereby consent to the release of the results of this medical examination and al l of my medical records to the company. I further release and forever discharge the company, the examining physician, and the medical testing organization from any and all c laims arising out of or in connection with the: (1) examination; (2) diagnosis or results of the examination; and (3) the company’s use of any diagnosis or results. Employee Signature __________________ Witness Signature ____________________ Printed Name _______________________ Printed Name ________________________ Social Security Number _______________ Social Security Number ________________ Date ______________ Date ______________