Physician's Statement Employee/ApplicantName First Last Four Social Security NumberTo be completed by PhysicianI have examined the individual named above and to the best of my knowledge he/she is good physical and mental health, free of any communicable diseases, and is able to function in his/her profession at full capacity. By signing below I certify that the above information is true.Name (Printed)Max. file size: 6 GB.Title (Must Circle One): MD DO NP PA APN APRN Physician Signature:Office Phone NumberDate of Exam: MM slash DD slash YYYY Address Street Address Address Line 2 Office Stamp
