Get Health Surveillance Clearance Form

Filling out the Health Surveillance Clearance Form online is a straightforward process that ensures your health information is documented correctly. This guide provides step-by-step instructions to assist you in completing the form accurately and effectively.

Follow the steps to successfully fill out the Health Surveillance Clearance Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Enter the patient's name in the designated field. Ensure to include the first and last name as it appears on official documents.
3. Fill in the date of birth (D.O.B) in the provided space. Format the date appropriately, using MM/DD/YYYY.
4. Indicate whether the patient has had a two-step TB test and/or Chest X-ray by selecting the appropriate checkbox. State clearly that the patient is free of disease.
5. Document the patient's immunity status against Measles, Mumps, Rubella, and Varicella. Choose between confirming known immunity or noting that the MMRV status is unknown with pending titre results.
6. Obtain the physician’s signature on the form, followed by the date. This signature validates the form's contents.
7. Enter the physician's phone number in the specified field for contact purposes.
8. If available, add the physician's stamp to the form as a further confirmation of authenticity.
9. Once all fields are completed, review your entries for accuracy. You can then save changes, download the completed form, print it, or share it as required.

Ensure your health documentation is complete by filling out the Health Surveillance Clearance Form online today.