Untitled Document
Untitled Document
Now Featuring
Untitled Document
Treatment Form
PATIENT/EMPLOYEE NAME:
SSN:
COMPANY NAME:
DATE OF BIRTH:
MM
DD
YYYY
PATIENT/EMPLOYEE PHONE #:
(
)
-
DATE OF INJURY:
MM
DD
YYYY
Work Related:
Injury
Illness
Post Accident Substance Abuse Testing:
Drug Screen
Breath Alcohol
Test Type:
DOT Regulated
Non-DOT
Billing:
Bill company for services
Employee to pay at time of service
Bill Workers' Compensation Carrier
Carrier:
Policy #:
Phone #:
(
)
-
Address:
Claim #:
Physical Examination/Services
Job Title:
DOT Pre-placement
DOT Recertification
Physical Examination (non-DOT)
Pulmonary Function Test
Hazmat
MDA
Audiogram
Lab Work
Hep A Immunization
Hep B Immunization
Influenza Vaccination
Tetanus Immunization
X-ray
TB test
EKG
Vision Testing
Other
Other/Notes
Test Type:
Pre-placement
Annual
Exit
Substance Abuse Testing:
Regulated (DOT)
Non-Regulated (non-DOT)
e-Screen (Instant)
Hair Collection
Breath Alcohol
Test Type (Please Check Reason):
Pre-placement
Random
Reasonable Suspicion
Post Accident
Periodic
Follow-up
Return to Duty
Observed
Authorized by:
Phone:
(
)
-
Title:
Date:
MM
DD
YYYY
Download
a hard copy of the form
here
and fax to (940) 766-6302.
NOTE: The form requires Adobe Acrobat Reader or equivalent PDF viewer.
Untitled Document
© 2006 All Rights Reserved Grace Medical Clinic • 1208 Brook Street • Wichita Falls, TX 76301 • (940) 761-3333
