Consent to Release Form

SIPS Consults is a staffing and consulting agency for Sterile Processing Departments throughout the United States. I authorize the release of my medical information to I hereby authorize the release of my medical information to SIPS Consults and any of its representatives, clients, and institutions, and any of its representatives, clients, and institutions. Please release my medical history including but not limited to: physical exams, vaccinations, and any additional health screenings and tests.
Standard Medical Requirements: Reference ranges must be submitted with titers reports. (1) Hepatitis B- Surface Antibody and Surface Antigen. If immunity is not present, dose #1 must be administered prior to hire. The remaining two (2) doses should be administered according to vaccination schedule issued by your physician. (2) Hepatitis C- Antibody (3) MMR- Rubella, Rubeola and Mumps. If immunity is not present, two (2) doses of the vaccination is required. (4) Varicella- IgG and IgM. If immunity is not present, two (2) doses of the vaccination is required. (5) QuantiFERON Gold Test- In-tube Assay. Accompanied by a recent 2-step PPD test. (6) Annual "fit for Duty" Exam.

Medical Professional/Facility

Medical Professional/Facility

SIPS Consults
4011 Shilling Way, Dallas, Texas 75237
Phone: 972.572.1988