Professional Documents
Culture Documents
Medical Consent/Authorization/Release
My signature below acknowledges that all statements provided by me in this application are true and correct to the best of my knowledge and belief, and I further authorize and consent to the
release of any/all of my medical records from any source, including nations insurance offices, doctors, hospitals, and/or other institutions or public authorities. This general medical release
will also authorize the release of any/all of my psychological or psychiatric records or referrals. I understand that falsification will be grounds for loss of benefits and/or
termination of employment. My signature further acknowledges my consent to any/all physical examinations and diagnostic testing:
Date:
HEIGHT: WEIGHT:
Vision adequate for
Color Vision position per Norwegian
______ Ishihara requirements?
______Snellen
______Bostrom Kugelberg _____Yes
______Passed _____No
______Not Passed
______Yes _____No
on provided _____Yes _____No
REQUIRED TESTS (Attach all LAB TEST results
to original)
Chest X-ray VDRL
Urinalysis Hepatits
Urine DrugA, B (PCP,
Test and C
CBC Benzodiazepines,
Chemistry-19 Panel Amphetamines, THC,
Opiates, Cocaine,
Barbiturates)
Pregnancy Test (all Female EKG (all over age 40)
NOTES/COMMENTS:_______________
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NOTES/COMMENTS:_______________
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