Copyright Envision Corporation. 2002. All rights reserved.

Protected by the copyright laws of the United States & Canada and by nternational treaties. ! S
""E#A" A$% S!&C!"' P&()*!E% !( %S!&*U!E+ PU*"S)+ (,,E& ,(& SA"E+ "CE$SE (& SU*"CE$SE+ #-E (& %SC"(SE !( A$' (!)E&
PA&!'+ !)S P&(%UC! $ )A&% C(P' (& %#!A" ,(&.. A"" (,,E$%E&S /"" *E SUE% $ A C(U&! (, "A/.
PHYSICAL EXAMINATION CONSENT AGREEMENT
This Physical Examination Consent Agreement ("Agreement") is made and effective this
[DATE],
BETWEEN: [EMPLOYEE NAME] (the "Emloyee"), an individ!al "ith his main
address at#
AND: [COMPANY NAME] 0the 1Co2pany13+ a corporation organi4ed and e5isting
6nder the laws of the 7S!A!E8P&(-$CE9+ with its head office located at:
n connection with 2y application for e2ploy2ent with the Co2pany+ hereby agree as follows:
$% TERMS
+ a c6rrent e2ployee of 7C(.PA$'9 0;the Co2pany<3+ 6nderstand that 2y c6rrent =ob re>6ires a
significant a2o6nt of physical activity and8or physical activity of a diffic6lt nat6re. 6nderstand that a
physical e5a2ination is necessary to assess 2y contin6ing fitness for the essential f6nctions of 2y =ob. n
consideration for 2y desire for a safe wor? environ2ent and for 2y own safety as well as the safety of 2y
fellow e2ployees+ give 2y consent for the Co2pany to cond6ct the physical e5a2inations it considers
necessary as o6tlined in its ;Physical E5a2ination< policy.
have the right to as? >6estions of the e5a2ining 2edical personnel+ and have the right to receive a
copy of the written eval6ation concerning 2y fitness to perfor2 the essential d6ties of 2y c6rrent =ob.
have the right to stop the e5a2ination at any point+ b6t s6ch an act 2ay =eopardi4e the stat6s of 2y
e2ploy2ent.
a6thori4e the laboratory or 2edical personnel retained by the Co2pany for the physical e5a2ination to
release the res6lts to the Co2pany for whatever 6se the Co2pany dee2s appropriate. ,6rther+ release
the laboratory or 2edical personnel cond6cting the e5a2ination+ the Co2pany+ and the Co2pany@s
e2ployees+ directors+ officers+ and s6ccessors fro2 any liabilities+ clai2s+ and ca6ses of action+ ?nown or
6n?nown+ contingent or fi5ed+ that 2ay res6lt fro2 this physical e5a2ination. agree not to file any laws6it
or other action to assert a clai2.
& have read and !nderstood this agreement, and & sign this "itho!t any coercion or d!ress 'y any
individ!al or instit!tion%
Physical E5a2 Consent Agree2ent
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Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by nternational treaties. ! S
""E#A" A$% S!&C!"' P&()*!E% !( %S!&*U!E+ PU*"S)+ (,,E& ,(& SA"E+ "CE$SE (& SU*"CE$SE+ #-E (& %SC"(SE !( A$' (!)E&
PA&!'+ !)S P&(%UC! $ )A&% C(P' (& %#!A" ,(&.. A"" (,,E$%E&S /"" *E SUE% $ A C(U&! (, "A/.
E.P"('EE C(.PA$'

A6thori4ed Signat6re A6thori4ed Signat6re

Print $a2e and !itle Print $a2e and !itle

Physical E5a2 Consent Agree2ent
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