medical authorization authorización medica consent to drug/alcohol

medical authorization authorización medica consent to drug/alcohol

MEDICAL AUTHORIZATION
You are hereby authorized to release to my employer any and all information, facts and
particulars, which may be requested regarding my physical condition and/or treatment rendered
to me and to permit my employer and any person appointed by my employer to examine all xrays or records regarding my physical condition or treatment and to obtain copies of such
records.
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Date
______________________________
Signature of Employee
AUTHORIZACIÓN MEDICA
Usted esta autorizado de revelar a mí (Patrón de Empleo) cualquier o toda información que le
puedan puedan pedir sobre mi condición física y tratamientas que sean de mi propiedad. Y
permetir a mí (Patron de Empleo) o personas autorizadas bajo esta firma de empleo de
examinar todos los documentos de rayos X. Y tratamienos físicos y personales.
__________________________________
Fecha
______________________________
Firma de empleo
CONSENT TO DRUG/ALCOHOL TESTING
I hereby consent to submit to a test or tests that are designed to detect the presence of drugs or
alcohol in my system, and I hereby agree that such test(s) may be performed by an accepted
method including testing of my breath, urine, saliva, or blood. I also consent to and authorize
the release of the results of my drug/alcohol test(s) to my employer, and its authorized agents. I
hereby release and hold harmless my employer and its employees and agents from and against
all losses and damages that I incur in any way from my drug/alcohol test(s).
I acknowledge that I may receive a copy of this consent upon request. I agree that a
photographic copy of the Consent is as valid as the original.
ACCEPTED AND AGREED this date:_________________________________________________
EMPLOYEE:
WITNESS:
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________________________________
________________________________
________________________________
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Employee’s Signature
Employee’s Printed Name
Employee’s Social Security Number
Witness’ Signature
Witness’ Printed name
Parent Signature (if employee under age 18)