Physician Statement

A Note of Importance:

Our medical facilities require a physician’s statement of good health that is updated yearly. This form must be filled out completely with the appropriate physician signature and information included. We must receive this completed statement before you begin employment, however do not delay in sending your completed application while getting this form completed. We will accept an alternate physician statement, but only if all the following information is included. Please remember to attach all copies of test results.

I hereby authorize the undersigned physician to release any medical information relevant to employment to Medical Staffing Partners. I also authorize Medical Staffing Partners to release this statement to any of its clients that I may be assigned to.

Or the following titres :

Measles – Vaccine after 1969 or titer. Exempt if born before 1957. No proof, revaccinate.
Rubella - Vaccine after 1970 or titer. Exempt if born before 1967 and > 55 years. Exception of < 55 years and female, exempt if had a hysterectomy, TL, post-menopausal. No proof, revaccinate.

Varicella states disease or titer done. If working in pediatrics and no disease, need titer.

PPD: Current within one year. If positive history – need CXR report

Hepatitis B – Immunization/titer. If refuse for any reason, need documentation.

I certify that I have performed a physical examination on the above mentioned individual and I further certify that this patient is in good physical and mental health, and is not suffering from any illness or physical or mental disability which would restrict him/her from providing services as a registered nurse.