T Other

Type of Substance Abuse Testing

T Preplacement T Reasonable cause

T Post-accident T Random

T Follow-up

Special instructions/comments:

Authorized by: Title: Please print

Phone: Date

Employer: Date of Birth: Location Number:

Work Related Physical Examination

T Injury T Illness T Preplacement T Baseline T Annual T Exit Date of Injury DOT Physical Examination Breath alcohol Special Examination

Substance Abuse Testing (check all that apply) T Preplacement T Recertification T Regulated drug screen T

T Collection only T Hair collect T Asbestos T Respirator T HAZMAT T Medical Surveillance

T Audiogram

T Non-regulated drug screen T Rapid drug screen T Human Performance Evaluation T Other

T Employee to pay charges

+ Due to the nature of these specific services, only the patient and staff are allowed in the testing/treatment area. Please alert your employee so that they can make arrangements for children or others that might otherwise be accompanying them to the medical center.

Street Address: Temporary Staffing Agency:

+

+

Billing (check if applicable)

(Copies of this form are available at www.concentra.com)

© 2008 Concentra Inc. All Rights Reserved. 06/08

(Patient must present Authorization and Photo ID at the time of service.) Authorization for Examination or Treatment

Patient Name: Social Security Number: Concentra now offers urgent care services for non-work related illness and injury. We accept many insurance plans.