21081 S. Western Ave. Suite 150, Torrance, CA 90501

Western Medical Group

Pre-Placement Physical Questions

  • This medical evaluation does not include all recommended clinical preventive services required to assess personal health status and should NOT be considered a substitute for regular medical evaluations performed by your personal health care provider. Please consult your personal M.D. for further information regarding those services.
  • I HEREBY CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE FOREGOING ANSWERS ARE COMPLETE AND CORRECT, AND I UNDERSTAND THAT ANY OMISSION OR FALSIFICATION OF THIS RECORDS CAUSE FOR TERMINATION. IF EMPLOYMENT IS OBTAINED UNDER THIS APPLICATION, I WILL COMPLY WITH ALL ORDERS, RULES AND REGULATIONS OF THE COMPANY. I CONSENT TO THE PROCEDURES WHICH MAY BE PERFORMED DURING THIS PHYSICAL EXAMINATION AT WESTERN MEDICAL GROUP INCLUDING SERVICES NOT LIMITED TO ANY LAB TESTS AND X-RAYS. FURTHERMORE, I AUTHORIZE WESTERN MEDICAL GROUP TO RELEASE ANY INFORMATION ON THIS FORM TO THE EMPLOYER UPON REQUEST.