Please fill out the below form to start the process. A doctor will reach out to you to schedule a mutually convenient time for your visit in the near future. TheraPeds Pre-Employment Childcare Clearance Examination Name * First Name Last Name Date of Birth * Email * Phone * (###) ### #### Medical Insurance Name (in case vaccine needed) * Insurance Policy Number * Insurance Group Number * Name of Primary Insured * Where would you like your visit? * Westlake - Meghan Lynch-Ljubi, DO Solon - Michael Perisa, MD By checking the box you certify agreement and understanding of the following Consent to Treatment: * I voluntarily request the indicated doctor to perform reasonable and necessary medical examination, and review of my medical information (including immunization history) as necessary to fill out a pre-employment childcare form. I understand I have the right at any time to discontinue services. I understand I have the right to discuss with the doctor the purpose, potential risks, and benefits of any recommended or provided immunization. I agree I do NOT agree and understand I will not receive a pre-employment childcare clearance examination. Thank you for requesting a Zest Pre-Employment Childcare Clearance Examination. We look to providing this service to you. A Zest doctor will follow-up with your shortly to schedule your visit.
