* = Required Information
I, give my permission to EZ Healthcare of Boston Group, Inc., designated and trained medical personnel to administer the PPD intradermal tuberculosis test and possibly administer the 2 stage test if necessary.

I further attest that to my knowledge I have never had a known positive reaction to the serum. Should I have a positive reaction when I return in 48 hours to have this test read, I will be referred to my physician or clinic where I could receive a chest X-Ray to be certain I do not have active tuberculosis.
Date of testing Planting site
Nurse administering test
Date of reading of the above test
Reading
neg pos
If positive
mm indurated
Nurse reading the test
If positive, to whom was applicant referred to
2 Stage Testing:
If applicant has not had tuberculosis test within 1 year, CDC guidelines recommend repeating the TB test in 2 week from the above test.
Date of testing Planting site
Nurse administering test
Date of reading of the above test
Reading
neg pos
If positive
mm indurated
Nurse reading the test
If positive, to whom was applicant referred to

 
Security Code *