Mandatory Physical Examination Verification form M4 Medical

MANDATORY PHYSICAL EXAMINATION VERIFICATION FOR FOURTH YEAR (M4) FAU MEDICAL STUDENTS
2015-2016
TO BE RETURNED BY PHYSICIAN (MD, DO), ARNP OR PHYSICIAN ASSISTANT DIRECTLY TO ADDRESS BELOW
PERSONAL INFORMATION
Last name
First name
Phone
Z number
Date of birth MM/DD/YY
Gender
Email address
To be completed by Physician (MD, DO), ARNP or Physician Assistant:
I have performed a complete history and physical examination on the student named above with the following results:
All findings were within normal limits
Follow-up care is recommended/ required; patient was advised
_____________________________________________________________________________________
_____________________________________________________________________________________
I certify that the information provided above is true and accurate to the best of my knowledge.
Physician’s _____________________________________________________________________________________
printed name:
An official stamp must appear here for forms and documents to
be approved.
Street Address
City
State
Zip
An official stamp must appear here for forms and documents to
be approved.
Physician (MD, DO), ARNP or PA signature:
Date
Return completed form by April 17, 2015 directly to: FAU Immunization Office, SU-80, Room 114, 777 Glades Road,
Boca Raton, FL 33431 (561) 297-0048 FAX (561) 297-2769