[NAME OF PRACTICE]
Employee: ______________________________________________________________________________
Last Name First Name Middle Name
Job Title: ______________________________________________________________________________
Employer: ______________________________________________________________________________
Address: _______________________________________________________________________________
Number & Street City State Zip
| WORK RELATED INJURY | ILLNESS |
| | |
|(Specify)___________________________________ |(Specify)___________________________________ |
|SUBSTANCE ABUSE DRUG SCREEN |OTHER |
| URINE | Audiogram |
|HAIR | |
| | |
|Type: | |
| | |
| | |
|DOT | |
|Non-DOT | |
| | |
| | |
| | |
| | |
|Reason: | |
|Pre-Employment | |
| | |
| | |
|Random | |
| | |
| | |
|Reasonable cause | |
| | |
| | |
|Post-Accident | |
| | |
| | |
|Follow-up | |
| | |
| | |
|Post-Injury | |
| | |
| | |
| | |
| | |
|Evidential Breath Testing (Alcohol) | |
| | |
| | |
| | |
|PHYSICAL EXAM | |
| | |
|Pre-Employment | |
| | |
|DOT Initial | |
| | |
|DOT Recert | |
| | |
|Return to Work | |
| | |
|Respiratory Evaluation | |
| | |
|Injury | |
| | |
| | Back Evaluation |
| | Chest X-Ray |
| | EKG |
| | Hepatitis B Vaccine |
| | Injection # 1 |
| | Injection # 2 |
| | Injection # 3 |
| | TB SKIN TEST |
| | Pulmonary Function Test (PFT) |
| | Tetanus |
| | Laboratory Collection |
| |SPECIAL INSTRUCTIONS: (Please Print) |
| |___________________________________________ |
| |___________________________________________ |
| |___________________________________________ |
| | |
| | Authorized by: (Signature) ______________________ |
| | |
| Name & Address where to send a Claim |Print Name:_________________________________ |
|__________________________________________ |We agree to pay for any medical treatment provided to the above named |
| |individual for the checked services. |
|__________________________________________ | |
|__________________________________________ |Phone:______________________________ |
| | |
|Note: Photo ID Required for all Services. |Date:_______________________________ |
................
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