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EMPLOYER'S AUTHORIZATION FOR EXAMINATION OR TREATMENT

(MUST PRESENT PHOTO ID AT TIME OF SERVICE)

Patient Name: CDL #:

Company Name: NATIONAL DCP

Address: **** ********* ****, # ***

Date of Birth:

City, State, Zip: DULUTH, GA 30096

*SUBSTANCE ABUSE TESTING*

NOTES TO CLINIC:

• QUEST LAB...