Substance Abuse Hr Manager

Concentra-

{Petient friust Prasent Photo D at Time of Seruice}

Authorization for Examination or Tieatment

Patient Name; Social Security Number:_ _

Employer: CroppMetca lfe- Fa i rfa x

Date of Birth

S*eerAddrerr,&21 Hllltop Rd, Fairfax, VA 22031

Locadon Number:

Temporary ScaffingAgency: _.

Work Related Phyeical Examinatlon

ftn;ury J-lttn"r, [-lPreptacement f]Basetine fllnnuat f]rrir Date of lnjury

Substance Abuse Testing* (check alt thar apply)

ft,egulared drug screen

ICottection onty [H"i

J-lNon-."gulated drug screen

DOT Phyricd Examination

Special Examination

[-l*o"r.o, llR"rpi.ato. Budiog."*

fp'.eatt alcohol

r collect

fo*"'

Type of Subitance Abure Testing

drug screen uman Performance Evaluation*

fJ'{edical Surveillance

IR"rron"ble cause

[-lR"nao*

Special instructions/commenrs: * Due to the namre of these specific services, only rhe patient and staff are allorned in the mstingltreatment area Plase alert your rnplope co that $ey can make arrangements for children or others that might otherwise be accompanying them co the medical center.

Ana Ferra HR Manager

Tide:

Please print

Phons,' 57t 237 - 3337

f]o

Billing (check if applicable)

fost-accident ftmgoyee to pay charges

floilow-uR

Concentra now offers urgent care services for non-work relared illness and iniury, We accept rnany insurance plans.

{Copss of this form are avallablo at v*tw.concentrr.com)

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