Statement of health form for employment 2026

1. Click ‘Get Form’ to open the statement of health form in our editor.
2. Begin by entering your Employee Name and Date of Birth in the designated fields at the top of the form.
3. In the authorization section, provide your consent for your healthcare provider to release your health information by signing and dating where indicated.
4. Fill in the Physician’s Office No. and Fax No. to ensure proper communication with your healthcare provider.
5. The physician will complete their section, confirming your health status. Ensure they print their name and sign it along with the date of last visit.
6. Proceed to the Immunization Statement section. Indicate whether you have received the Hepatitis B vaccine or decline it, and provide relevant dates for vaccinations.
7. Complete any additional vaccination details for Tuberculosis, MMR, and Varicella as required, ensuring all dates are accurately filled in.

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