Physician’s Statement and Vaccination Record

I, _________________________, authorize the Physician/ Nurse Practitioner named below to

           (Please print)

 release to Not Just Nurses, Inc. any information acquired in my medical examination that is relevant to my contract.

___________________________                      _________________________               

                Signature                                                                                                           Date

     The above mentioned person has been examined by me, and to the best of my knowledge, he/she is in good physical health, free of any back problems, free from any communicable diseases and able to function in his/her profession at full capacity with no limitation.

Physician’s Name ________________________  License # _____________________

Signature ______________________________ Office Phone # __________________

Date of exam _______________

PPD/TB Test                            Date:           _____ Result_________________

Chest X-Ray (If Positive PPD)         Date: __________ Result ___________ ___ ____

Varicella Titer                           Date: __________ Result __________Immunity present? ____

Rubella Titer                            Date: __________ Result __________Immunity present? ____

Immunization dates Dose # 1  ___________  Dose # 2  ______________ History of disease_______________

Rubeola Titer                           _______________     ______________ Immunity present? ____

Immunization dates      Dose # 1  ___________  Dose # 2  ______________ History of disease_______________

MMR Vaccine            Dose #1________ Dose #2 ________

Hepatitis B  Vaccine  Dose #1________ Dose #2 ________ Dose #3 ___________                              

Hepatitis B Titer         Date: _______ Result: ________ Immunity present? ___________

Hepatitis Vaccine Waiver

 I, __________________, acknowledge that I am at risk of exposure to Hepatitis B as a result of my

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occupation and

________ have already received the Hepatitis Vaccine.

________ refuse the hepatitis vaccine and hold Not Just Nurses, Inc. harmless.

Signature: ___________________                    Date: ________

Witness: ______________________                   Date: ________