Complete all fields. Use “N/A” where a question does not apply. You will sign electronically at the bottom; your submission is emailed securely to our clinic.
Información del paciente — Please complete all blocks.
English. I understand that The Port Clinic conducts 24 hours/7 days a week surveillance through video monitoring of its waiting areas, hallways and physical therapy treatment areas and audio monitoring of its telephone calls for quality assurance purposes and to ensure the safety of property, patients, and employees of The Port Clinic.
I understand that these videos and audio recordings may or may not contain protected health information, are stored in a secure manner, and may only be disclosed to third parties in accordance with The Port Clinic.
Español. Entiendo que The Port Clinic realiza vigilancia las 24 horas/7 días a la semana a través del monitoreo por video de sus áreas de espera, pasillos y áreas de tratamiento de fisioterapia y monitoreo de audio de sus llamadas telefónicas con fines de garantía de calidad y para garantizar la seguridad de la propiedad, los pacientes y empleados de The Port Clinic.
Entiendo que estas grabaciones de video y audio pueden o no contener información de salud protegida, se almacenan de manera segura y solo se pueden divulgar a terceros de acuerdo con la política de privacidad de The Port Clinic.
I hereby authorize The Port Clinic to conduct a pre-employment physical screening on the above-mentioned employment candidates.
I understand that it is only a physical examination and does not constitute a formal doctor/patient agreement. I am also aware that The Port Clinic may use numerous physicians, residents, nurse practitioners or physician assistants who may participate in or perform the physical examination. I authorize their assistance in participating and/or performing the physical.
I also understand that this examination is designed to determine the difficulties which may arise with my employment, and is not a complete physical examination designed to detect a rare or occult disease.
I hereby release The Port Clinic, as well as their staff, from all liability which may arise from the administration of this physical examination, whether foreseen or unforeseen. If a health problem is found, I understand that The Port Clinic physician will inform me of any need for further medical attention. I have read and understand this acknowledgment form.
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