PRIVACY ACT MATERIAL REMOVED ny HOLMES & NARYER, INC. MEDICAL REFERRAL TECHNOLOGY & PATE: 12 Dec. 1972 CONSTRUCTION : PACIFIC TEST DIVISION AEC CONTRACT AT(29-2)-20 REPOSITORY J COLLECTION ro. ACA AST Maui Medical Group D0 E/VV 28 “ BOXNo. 4p 2180 Main St. . Wailuku, Hawaii re DoE/PA So FOLDER “Eeoa *3" 35 COUPAD Of zhaw (2f 1923 ; , WHOSE SIGNATURE APPEARS BELOW IS REFERRED TO YOU FOR THE FOLLOWING LISTED MEDICAL SERVICES IN ACCORDANCE WITH THE TERMS OF OUR PURCHASE ORDER NO. 9E055 APPLICANT HAS AN APPOINTMENTaFOR Hours on ; BESCRIP TION: 12 Dec 1972 AUTHORIZED FURNISHED IF CHECKEO DATE PRE-EMPLOYMENT EXAMINATION TERMINATION EXAMINATION RH FACTOR & BLOOD TYPE STOOL EXAMINATION OTHERMeo cs aeRSES {LIST) IMMUNIZATION — x . J2- (xv “TD IF CHECKED, REQUIREMENTS FOR THE FOLLOWING INOCULATIONS ARE DETERMINED BY THE PHYSICIAN, NORMALLY FROM THE SHOT RECORD CARD: SMALLPOX VACCINATION TETANUS TOXOIO INOCULATION TYPHOID /PARATYPHOID INOCULATION POLYVALENT INFLUENZA V!RUS INOCULATION SABIN ORAL VACCINE CHOLERA INOCULATION APPLICANT WILL READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING TKIS FORM. | AUTHORIZE THE MEDICAL EXAMINER TO OISCLOSE ALL RELEVANT MEDICAL INFORMATION TO HOLMES & NARVER, INC., REGARDING MY MEDICAL HISTORY AND PHYSICAL EXAMINATION STATUS. * 4 APPLICANT: SIGNATURE , AUTHORIZED REPRESENTATIVE ktm. of Lpiroatanesf tld, hat INSTRUCTIONS TO THE PHYSICIAN: | : nL ete teHetf-2 Lh RETAIN THIS FORM. AS IT MUST BE ATTACHED TO THE SUMMARY OF CHARGES FOR MEDICAL SERVICES FORM WHEN SUBMITTEO FOR PAYMENT. PRIVACY ACT MATERIAL REMOVED