Act Now DME Medical Release of Information

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  • Medical Release


    Please Download and Print Medical Release Form Here

    Please also upload the following files:
    • Immunizations
    • Current Physical

    Please note: If you do not have any of these files immediately available, please upload everything else now, then send the remaining documents to hr@actnowdme.com.. This WILL delay the processing of your application.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, doc, docx.
  • HEPATITIS B VACCINATION

    I have already received the hepatitis B Vaccine.
    I decline the hepatitis B Vaccine.
    If interested with the hepatitis B vaccine, I may contact the local Health Department.


    I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine; I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series.
  • Tetanus Vaccination

    I understand that I have been requested to supply proof of Tetanus Vaccination or agree to the vaccination prior to placement with Act Now DME, LLC. However, I decline the Tetanus Vaccination. Further, I understand that my refusal may limit my placement options in that I understand I cannot be placed at an Act Now DME client (hereinafter “Facility”) that requires the Tetanus Vaccination.
  • Therefore, in consideration of my employment with Act Now DME and placement at a Facility, I agree to hold harmless both Facility and Act Now DME, their owners, directors, employees, staff, and agents, from any and all liability arising out of my refusal of the Tetanus Vaccination.