Medical Examination Form for American Nanny Company Applicants

Please have your physician complete this form.

This is to certify that I have examined _______________________________, nanny candidate, and find no conditions that would interfere with her/his ability to perform the duties of nanny with the exception of the following:

Date Mantoux given: ______________________
Date Mantoux read: ______________________
Results: _______________

I further find no indication of any condition which could present a possible hazard to the health of the children and/or other family members.

Physician’s name: _______________
Address: _______________
Telephone number: _______________

Signature of physician: _______________ Date: _______________

If you have any questions please call us at 1-800-262-8771.

INSTRUCTIONS:
Please print this form, have your physician complete this form and send it back to the American Nanny Company using one of the following methods:
U.S. Mail:   American Nanny Company
or
 Fax:   1-617-969-1269
    PO BOX 765 Newtonville Branch
    Boston, MA 02460
Autobiographical Letter | Medical Information Form | Medical Examination Form
Information Verification Release (Graham/Sheehan) | Return to Forms Index