Applicant's Name I hereby authorize the Physician named below to release to PRN, Inc. any information acquired in my recent medical examination which may be relevant to my potential employment.

Today's Date (DD/MM/YYYY)  /   / 

Signature of Employee

Email

I have examined Applicant's Name and to the best of my knowledge she/he is in good physical and mental health and free of any communicable disease and should be able to function in her/his profession without any limitations whatsoever.

Patients date of birth (DD/MM/YYYY)  /   / 

Patient Social Security #

(Date of physical) (DD/MM/YYYY)  /   / 

(Physician Signature)  

Physician Name  

Physician Address

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