PRIVACY ACT MATERIAL REMOVED
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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