MANDATORY PHYSICAL EXAMINATION VERIFICATION FOR FOURTH YEAR (M4) FAU MEDICAL STUDENTS 2015-2016 TO BE RETURNED BY PHYSICIAN (MD, DO), ARNP OR PHYSICIAN ASSISTANT DIRECTLY TO ADDRESS BELOW PERSONAL INFORMATION Last name First name Phone Z number Date of birth MM/DD/YY Gender Email address To be completed by Physician (MD, DO), ARNP or Physician Assistant: I have performed a complete history and physical examination on the student named above with the following results: All findings were within normal limits Follow-up care is recommended/ required; patient was advised _____________________________________________________________________________________ _____________________________________________________________________________________ I certify that the information provided above is true and accurate to the best of my knowledge. Physician’s _____________________________________________________________________________________ printed name: An official stamp must appear here for forms and documents to be approved. Street Address City State Zip An official stamp must appear here for forms and documents to be approved. Physician (MD, DO), ARNP or PA signature: Date Return completed form by April 17, 2015 directly to: FAU Immunization Office, SU-80, Room 114, 777 Glades Road, Boca Raton, FL 33431 (561) 297-0048 FAX (561) 297-2769
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