Authorization for Medical Test

I, THE UNDERSIGNED, declare that I am a competent adult at least 18 years old. I hereby grant permission for the following medical test to be performed on me:

I further acknowledge that such tests may involve the temporary invasion or penetration of my body by medical instruments, light, sound, x-rays, or other maging and diagnostic media, and may further involve the obtainment of bodily fluids, tissue, products or waste, all oi which I give up any claim to.

I further certify that all such contemplated tests have been explained to me and that I have provided complete and honest responses to all questions posed to me regarding my health, including pregnancy, disabilities, allergies, and susceptibilities, if any.

I understand that these medical tests are not being performed for my benefit, but are instead performed for the benefit of______________________, which I hereby release from any and all responsibility for treatment. advice, referral, or diagnosis.

I grant this authorisation in exchange for the opportunity to be considered for employment, or for advancement in employment, or because such testing is required by law, and I acknowledge such testing is necessary and relevant to my employment.

I voluntarily make this grant without reservation.

Signed and dated this ____________ day of ___________ 20 __.

_________________________

Applicant

Witnessed by: _________________________