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PHYSICAL EXAMINATION CONSENT AGREEMENT



This Physical Examination Consent Agreement ("Agreement") is made and effective this [DATE],


BETWEEN:  [EMPLOYEE NAME] (the "Employee"), an individual with his main address at:[COMPLETE ADDRESS]


AND:  [YOUR COMPANY NAME] (the "Company"), a corporation organized and existing under the laws of the [State/Province] of [STATE/PROVINCE], with its head office located at:[YOUR COMPLETE ADDRESS]


In connection with my application for employment with the Company, I hereby agree as follows:


TERMS


I, a current employee of [COMPANY] (the Company), understand that my current job requires a significant amount of physical activity and/or physical activity of a difficult nature. I understand that a physical examination is necessary to assess my continuing fitness for the essential functions of my job. In consideration for my desire for a safe work environment and for my own safety as well as the safety of my fellow employees, I give my consent for the Company to conduct the physical examinations it considers necessary as outlined in its Physical Examination policy. 

I have the right to ask questions of the examining medical personnel, and I have the right to receive a copy of the written evaluation concerning my fitness to perform the essential duties of my current job. I have the right to stop the examination at any point, but such an act may jeopardize the status of my employment. 

I authorize the laboratory or medical personnel retained by the Company for the physical examination to release the results to the Company for whatever use the Company deems appropriate. Further, I release the laboratory or medical personnel conducting the examination, the Company, and the Companys employees, directors, officers, and successors from any liabilities, claims, and causes of action, known or unknown, contingent or fixed, that may result from this physical examination. I agree not to file any lawsuit or other action to assert a claim. 

I have read and understood this agreement, and I sign this without any coercion or duress by any individual or institution.


EMPLOYEE            COMPANY

                          
Authorized Signature          Authorized Signature

                          
Print Name and Title          Print Name and Title
 

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