Full Name: Date:

Course Completed:  

Please select below the option you agree upon.

• For Clinical Medical Assistant (CMA): CPR/BLS Healthcare Certification (cannot be online test) & TB (Tuberculosis) skin test. (Hepatitis B vaccine, Drug Screening and Background Check might be necessary based on the facility). Proof of good standing with school loan, if tuition is financed.
• For Dental Assistant (DA): CPR/BLS Healthcare Certification (cannot be online test) & Hepatitis B vaccination (Drug Screening and Background Check might be necessary based on facility). Proof of good standing with school loan, if tuition is financed.
• For Pharmacy Technician (PhT): CPR/BLS Healthcare Certification (cannot be online test). State Registration, Drug Screening and Background Check. Proof of good standing with school loan, if tuition is financed.

Terms and Conditions for Completing the Observation/Extern Hours: 

1. 1. By accepting to complete the optional observation hours, I am responsible for having proof of up to date records for the following items listed below (dependent on course completion) and understand that this must be submitted to the instructor(s) no later than 7 days after this form is completed. *Failure to do so will result in the school no longer being held responsible for locating an observation site.* 
   2. Once the school has located an observation site, I understand that I must have ALL required forms completed and submitted to the instructor(s) before start date of site placement. *Failure to do so will result in the school no longer being held responsible for student to start observation site nor complete any hours.* (These forms include: Statement of Agreement Guidelines, Student Placement of Observation Site, and Syllabus/Guidelines. The Weekly Time Sheets should be submitted to the instructor(s) weekly of accurate documented hours and must be signed by the site’s supervisor). 
   3. By accepting to complete the optional observation hours, you are understanding that MedCertify can place you within 100 miles of your residential address. 

Terms and Conditions for Rejecting the Observation/Extern Hours:

1. 1. By rejecting to complete the optional observation hours, I am responsible for finding my own observation site if I choose to work on completing observation/extern hours. I understand that MedCertify.com is no longer held responsible for locating an observation site for me to complete hours.

Select whtether you accept or reject the observation/extern hours:

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Document name: Course Completion

Unique Document ID: 55914376a37f97a7a89ddd648abd21cd75e6b5d5

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Timestamp	Audit
February 18, 2022 11:01 AM EDT	Course Completion Uploaded by MedCertify Education - [email protected] IP 99.190.9.234
February 18, 2022 11:10 AM EDT	MedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234
May 2, 2023 1:23 PM EDT	MedCertify Edu - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234

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https://medcertify.com/

Audit Trail Serial# 67f1d6cf6944b0c134739a1282a3b0c0