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Doctors Report Form

To be completed by a licensed medical practitioner who is the participant’s regular GP and who is familiar with the participant’s health history. It is not acceptable for the completing practitioner to be an immediate family member of the applicant.

 
















Vaccinations

Please discuss the following and advise as you feel appropriate. Please record dates of any vaccinations if known.








Overall Recommendation

I have read the applicant's Medical Form and I have examined
(patient’s name)
(years)

In my opinion, the applicant is physically, mentally and emotionally capable of participating in the March of the Living program: