Scribd Logo
Upload

Welcome to Scribd!

  • 59 views

    Medical Clearance Form

    Uploaded by

    Samantha Catilo
    This medical clearance form collects information about a student's name, ID number, and upcoming clinical rotation date. It also requests contact information for the medical practice office where the student will complete their rotation. The form requires a medical practitioner's signature to verify the student is in adequate health for direct patient contact or to note any concerns that may pose a risk. Additional comments can also be included.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Clearance Form

    Uploaded by

    Samantha Catilo
    59 views1 page
    This medical clearance form collects information about a student's name, ID number, and upcoming clinical rotation date. It also requests contact information for the medical practice office where the student will complete their rotation. The form requires a medical practitioner's signature to verify the student is in adequate health for direct patient contact or to note any concerns that may pose a risk. Additional comments can also be included.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This medical clearance form collects information about a student's name, ID number, and upcoming clinical rotation date. It also requests contact information for the medical practice office where the student will complete their rotation. The form requires a medical practitioner's signature to verify the student is in adequate health for direct patient contact or to note any concerns that may pose a risk. Additional comments can also be included.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    59 views1 page

    Medical Clearance Form

    Uploaded by

    Samantha Catilo
    This medical clearance form collects information about a student's name, ID number, and upcoming clinical rotation date. It also requests contact information for the medical practice office where the student will complete their rotation. The form requires a medical practitioner's signature to verify the student is in adequate health for direct patient contact or to note any concerns that may pose a risk. Additional comments can also be included.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MEDICAL CLEARANCE FORM

    STUDENT INFO
    Name: _____________________________________________
    ID Number: ______________________
    Date of 1st Clinical Rotation: ____________________

    MEDICAL PRACTICE OFFICE INFOR


    Name of Facility: _____________________________________
    Address: ____________________________________________
    Phone Number: ______________________________________

    MEDICAL CLEARANCE

    This student is in adequate physical and mental health to provide services in a


    direct contact clinical environment.

    This student presents concerns that may be a potential risk to the student or
    others. Please explain:
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________

    ADDITIONAL COMMENTS
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________
    __________________________________________________________________

    MEDICAL PRACTITIONER’S INFO


    Signature: ________________________________________________
    Printed Name _____________________________________________
    Date: ____________________________________

    SOURCE: https://images.sampleforms.com/wp-content/uploads/2017/09/Student-Medical-Clearance-Form-11.jpg?width=390

    You might also like