Medical Examination Consent
[Your Company Name]
Full Name: | [Your Name] |
Date of Birth: | [MM/DD/YYYY] |
Position: | |
Date: | [Date] |
Consent Approval: |
I, [Your Name], hereby give consent for the company [Your Company Name] to carry out a medical examination as part of the employment process or ongoing employee health surveillance. I confirm that I have read and understood the consent. |
Signature: | |
|
Confidentiality:
I understand that the results of this examination will be kept confidential and will only be disclosed to authorized personnel who require this information for employment-related decisions.
Consent to Release Information:
I authorize the medical professional and [Company Name] to share necessary medical information with each other regarding the results of the examination for employment-related purposes.
Right to Refuse:
I acknowledge that participation in this examination is voluntary, and I have the right to refuse to undergo any part of the examination. However, I understand that such refusal may affect my employment status with [Company Name].
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