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Physical Examination for Admission to Portage Manor Licensed Residential Care Facility

  1. sign
  2. Physical Examination for Admission to Portage Manor Licensed Residential Care Facility
  3. Physical examination will be needed by a licensed physician after the applicatant has been accepted for admissions.
  4. Please read Mantoux in millimeters at 72hrs; required within 3 months of admission.
  5. Chest X-Ray must be done within 6 months prior to admission if Mantoux is positive and/or contraindicated.
  6. Free of Tuberculosis:
  7. Free of Communicable Disease at time of exam:
  8. Diagnosis:
  9. General Exam
  10. *All areas of the form must be completed and signed by physician for Admission
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  12. This field is not part of the form submission.