EMPLOYER'S AUTHORIZATION FOR EXAMINATION OR TREATMENT
(MUST PRESENT PHOTO ID AT TIME OF SERVICE)
Employee (Patient) Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Employer Name
*
Employer Address
*
Office Patient will be seen at:
*
Please Select
Bellmawr, NJ
Bordentown, NJ
Burlington, NJ
Hoboken, NJ
Dresher, PA
King of Prussia, PA
Perth Amboy, NJ
Pennington, NJ
Somerset, NJ
Spotswood, NJ
Trexlertown, PA
Unsure
Multiple Offices
Reason(s) for Visit?
*
DOT Physical
Drug and Alcohol Testing
Pre-Employment Physical
Return to Work Physical
Illness
Injury
Other
Type of Drug Test?
BAT (Breath Alcohol Test)
Hair Collection
DOT Urine (5 Panel)
NON DOT Urine (5 Panel)
NON DOT Urine (5+ Panel)
Reason for Drug Testing
Pre-employment
Random
Post Accident
Additional Services
Audiometry
Lift Test
OSHA Respiratory Questionairre
Respiratory Qualitative Fit Test
TB Skin Test
TB Chest X-Ray
TB IGRA (Quantiferon TB Gold)
TDAP (Tetanus Shot)
Other
Designated Employer Representative (Full Name)
*
Title/Position
*
Please Select
CEO/COO
Human Resources
Manager
Owner
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Signature
*
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