Employee Registration for Cholinesterase Program
Unidad Medica Santa Maria Valley
Cholinesterase Monitoring Program
Medical Director: Paul Christensen MD
Please enter the following information to register an employee into the cholinesterase monitoring program. A signed California Pesticide Medical Supervision Agreement is required to enter an employee into the program.
Registration fee is $250 which includes baseline testing and initial examination. Submission of this document serves as authorization for billing of the registration fee and testing as required of the cholinesterase monitoring program.
Employees are monitored at 30-day intervals for the initial 3 months and if stable the interval is advanced to 60 days. This interval may change based upon medical director discretion.
Employer
Company Name:
*
Designated Representative:
*
Title:
*
Signature:
*
Date:
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee
Name
*
First Name
Last Name
DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Job Title:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Format: (000) 000-0000.
Email:
example@example.com
Registration is based upon the calendar year without proration.
124 West Fesler Street
Santa Maria, CA 93458
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