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Annually thereafter I will submit Page 2 to verify my health status for clinicals and will notify the School of Nursing if changes at any other time. Student signature Date Student printed name DOB HEALTH PROFESSIONAL COMPLETE THIS SECTION student must use this form The student named above has had a complete physical examination and has no restrictions Note to physician If restrictions do exist please attach explanation. Date of this physical examination was Month Day Year Signature...
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Student must complete this section by providing all necessary information.
Any student who is requested to do so by the relevant authorities.
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The purpose of this section is to gather relevant information about the student.
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