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Annual Health Assessment form

You can have a blank Annual Health Assessment form faxed directly to your doctor’s office. This way, your doctor will already have the form when you go to your doctor’s appointment.

Enter your doctor’s office fax number here:

You must fill out everything before you can submit your Annual Physical form.
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Does your completed Annual Health Assessment form have:

Your full name, date of birth, date of visit at the top?

Your PPD results filled in or your QuantiFERON results?

Your doctor's signature and stamp?

Submit your completed Annual Health Assessment form here

Max file size 10MB.
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