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Health Certification Form

DOS-1948 (Rev. 04/18) Page 1 of 1 Division of Licensing Services Box 22001 Albany, NY 12201-2001 Customer Service: (518) 474-4429 Health Certification Form To the Health Care Professional: This form should be used for patients who need to be examined by a physician, physician assistant or a nurse practitioner to apply for a license in the appearance enhancement or barber industry. Please complete the below portion of this form and sign and date the form.

You need to have a physical examination to apply for a license in Cosmetology, Esthetics, Nail Specialty, Natural Hair Styling, Waxing and Barbering. Your physician, physician assistant or a nurse practitioner must complete, sign and date this Health Certification.

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