Physical Examination Consent Form

Physical Examination Consent Form for Applicants

[Company Name]

I ______________ a prospective employee of [Company Name] understand that I am required to undergo a physical examination to determine my fitness for the job duties, due to the nature of the job.  In order to create and maintain a safe work environment, I hereby give my consent for [Company Name] to conduct the physical examinations it considers necessary as outlined in its "Physical Examination" policy.  I fully understand that this exam is a condition for employment.

I authorize the laboratory or medical personnel to release the results to the Company for whatever use the Company deems appropriate.  Further, I release the laboratory or medical personnel conducting the exam, the Company, and the Company´s employees, directors, officers, and successors from any liabilities, claims, and causes of action, known or unknown, contingent or fixed, that may result from this physical examination.  I agree not to file any lawsuit or other action to assert a claim.

I have read and understood this agreement, and I sign this without any coercion or duress by any individual or institution.

____________________________

Print Name

________________________

Signature

____________

Date