Tb xray ala moana form 2026

1. Click ‘Get Form’ to open the tb xray ala moana form in our editor.
2. Begin by entering your name in the designated fields for LAST, FIRST, and MIDDLE. Ensure that you type or print clearly.
3. Fill in your SEX, DATE OF BIRTH, and STREET ADDRESS along with any apartment number if applicable. Continue with CITY, STATE, and ZIP CODE.
4. If your mailing address differs from your street address, complete the MAILING ADDRESS section with the same details: CITY, STATE, and ZIP CODE.
5. In the signature section, sign your name in INK as it appears on your application. This must be done in the presence of the examining physician.
6. For the Tuberculosis Test section, enter the DATE OF TEST RESULT and circle the TYPE OF TEST (Skin Test or X-Ray). Fill in the RESULT field accordingly.
7. Complete the Licensed Medical Provider's information by providing their signature, date, name, title, and business name and address.
8. Repeat similar steps for the Syphilis Blood Test section by entering relevant details including DATE OF TEST RESULT and RESULT.

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