DIY Legal Forms

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Medical Consent

Date:

TO WHOM IT MAY CONCERN

For the limited purpose of consideration of employment with [Name], I, the undersigned individual, asserting that I am over the age of majority do authorize the following medical examination: [Enumerate].

I realise that the medical examination will be conducted for the benefit of my prospective employer and will be included as a part of my prospective employer's determination whether to extend an offer of employment to me.

I release both the medical professional who will conduct such tests and [Name] from all liability for diagnosis and treatment. I voluntarily authorize this consent without limitation or uncertainty.

Signature

Name of Undersigned

This Section for Notary:

Acknowledgment

STATE OF -------)

) ss: [Date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

[Signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)