AUTHORIZATION FOR MEDICAL TREATMENT
1530 East Edinger Ave., Suite 1
Santa Ana, California 92705
Phone Number: (714) 442-0600 Fax Number: (714) 542-0038
Date
/
Month
/
Day
Year
Date
Medical Services
Work Injury
Modified Work Available
Drug Screen - DOT
Drug Screen - Non-DOT
Rapid Drug Screen
Physical
Covid-19 Test / Vaccine
TB Test
Hep B
Other
Physical Exam Info (briefly)
(Post-offer, DOT, special requests)
Brief description of injury
Date of injury
-
Month
-
Day
Year
Date
Patient / Employee name
Employer/Company Name
Other Instructions / Clinic requests
(eg. post-accident protocol requests, post-clinic visit requests, etc)
Workers Comp. Insurance Info
Name
Exp. Date
/
Month
/
Day
Year
Date
Policy Number
Treatment authorized by
Title
Contact Name (Print)
Telephone
Format: (000) 000-0000.
Email Address
example@example.com
Photo ID required at time of visit.
1530 East Edinger Ave., Suite 1
Santa Ana, California 92705
OPEN 24 HOURS
Please contact clinic if your employee requires transportation.
FOR LIFE THREATENING EMERGENCIES CALL 911
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