For the limited purpose of consideration of employment with ___________, I, the undersigned individual, asserting that I am over the age of majority do authorize the following medical examination:

I realise that the medical examination will be conducted for the benefit of my prospective employer and will be included as a part of my prospective employer's determination whether to extend an offer of employment to me.

I release both the medical professional who will conduct such tests and ______________ from all liability for diagnosis and treatment. I voluntarily authorize this consent without limitation or uncertainty.

______________________________

Undersigned