(By Applicant or Employee)

I, (name of applicant or employee), do voluntarily consent to a medical examination conducted at the request of XYZ Employer.  The purpose and procedures of the examination have been fully described to me and I completely understand the reasons and potential uses of the examination.  I agree that the results of the medical examination will be given to XYZ Employer with a copy given to me.

The cost of this examination will be paid by XYZ Employer at no cost to me and the results will be kept as confidential as possible.  Although XYZ Employer may not discriminate against me in any way as a consequence of the result of the test, I nonetheless hereby indemnify, release and forever discharge XYZ Employer, the Examining Physician, and his employer if applicable, from any and all claims, demands, judgments and legal fees arising out of or in connection with the examination, diagnosis or results or the use of any diagnosis or results thereto.