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Authorization for Medical Test

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Authorization for Medical Test

Authorization for Medical Test

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Authorization for Medical Test
I, THE UNDERSIGNED, declare that I am a competent adult at least 18 years old. I hereby grant permission for the following medical test to be performed on me:
I further acknowledge that such tests may involve the temporary invasion or penetration of my body by medical instruments, light, sound, x-rays, or diagnostic media, and may further involve the obtainment of bodily fluids, tissue, products or waste, all of which I give up any claim to.
I further certify that all such contemplated tests have been explained to me and that I have provided complete and honest responses to all questions posed to me regarding my health, including pregnancy, disabilities, allergies, and susceptibilities, if any.
I understand that these medical tests are not being performed for my benefit, but are instead performed for the benefit of:
___________________________________________________________________,
Employer Name

which I hereby release from any and all responsibility for treatment, advice, referral, or diagnosis.
I grant this authorization in exchange for the opportunity to be considered for employment, or for advancement in employment, or because such testing is required by law, and I acknowledge such testing is necessary and relevant to my employment.
I voluntarily make this grant without reservation.
Signed and dated this ____________ day of _________________ 20 ____, by
Employee’s Name: _________________________________________________________



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