Physician’s Statement

I hereby authorize Agency Staffing to use or disclose this information to its client facilities, which may be relevant in evaluating my qualifications for employment opportunities and related activities.

Applicant Signature

Date

I certify that (enter name below) is in good physical and mental health, free of any communicable diseases, and is able to physically perform the job functions without restrictions

First Last

Patient’s Social Security Number

Patient’s Date of Birth

Physician’s Signature

Date of Medical Examination

Physician’s License Number

Name

First Last

Physician's Name

First Last

CLINIC STAMP: (Please make sure to have this stamped by the clinic)

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Restoration Path Home Care is your trusted companion, providing exceptional, personalized in-home assistance, fostering independence, and enhancing the quality of life.

“But by Love, Serve one another”, Galatians 5:13

Physician’s Statement

Physician’s Statement

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