Shiatsu School of Canada Inc.
547 College Street, Toronto, Ontario M6G 149
(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:

Date:

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

Comments:

(   ) Results of T.B. Test

Comments:

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