Shiatsu School of Canada Inc.
455 Spadina Ave., Suite 300, Toronto, Ontario M5S 2G8
(416) 323-1818  Toll Free (800) 263-1703  Fax (416) 323-1681

Medical Form to be Filled out by Doctor

Please print and take this medical form to your doctor (M.D.) to be filled out.

Medical Form

Applicant Name:


(   ) Is the above in good health and free of communicable diseases?




(   ) Results of T.B. Test




Is the above named person fit, healthy and able to work with the public?

(   ) Yes           (   ) No

If No, please explain why.  Thank You




____________________              ____________________
Doctor's Name (please print)                     Doctor's Signature