I hereby certify that all the information I have disclosed, as reflected in this report, is true to the best of my knowledge and belief. I understand that any misrepresentation or concealment on my part may lead to consequences, including but not limited to termination, legal prosecution, expulsion, and disqualification.

I hereby authorize Bohol Family Wellness Medical and Diagnostic Center and its officially designated examining physicians and staff to conduct the examinations necessary to assess my fitness to work.

I give my consent to Bohol Family Wellness Medical and Diagnostic Center Inc. and its officially designated examining physicians and staff to furnish the results of this examination to my employer/potential employers or their authorized representatives.

I hold Bohol Family Wellness Medical and Diagnostic Center and its authorized physicians and staff free from any criminal, civil, administrative, ethical, and moral liability that may arise from the above.

By proceeding to this, I hereby authorize the release of all my medical records to my employer /potential employers or their authorized representatives, as well as to Bohol Family Wellness Medical and Diagnostic Center.