Fillable Physicians Report Last First Middle I am applying (Santa Ana College)

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Physicians Report Last First Middle I am applying (Santa Ana College)

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Physicians Report
Student Name:
Last First Middle
Date of Birth:______________________________________
mm/dd/yyyy
I am applying to study at Santa Ana College. As part of the admission requirements, I have been asked to submit my TB
test results to the school that I am applying for admission. Therefore, I give permission to my physician(s) to release the
information requested on this form.
Date: __________________________ Applicant’s Signature:_____________________________________________
mm/dd/yyyy
A.
Test Results:
TB Mantoux test done
on:
Test was read on:
_________________________________
mm/dd/yyyy
_________________________________
mm/dd/yyyy
He/She is in ________________________ general physical condition and is free from active
tuberculosis.
Blood Pressure______________________________
B.
Health Problems:
Allergies
Medications Taken
C. Additional Comments:
D. Physician:
Name of Physician
Signature Date
Address
Telephone Fax
ALL SECTIONS OF THIS FORM MUST BE COMPLETED.
Official Seal or Stamp
IMPORTANT: Attach a copy of the TB test result. If the TB test is positive, also include chest x-ray report.
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Physicians Report Last First Middle I am applying (Santa Ana College)

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Completed 6 September 2020

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