Authorization Form for Industrial Care Only
Your single source for occupational medical services.

Employer Employee Authorized By Email Address Date

Please Check Appropriate Boxes for Examination or Treatment

Drug Screen Post-Offer Random For Cause Physical Examination Pre-Placement     D.O.T. Certification     D.O.T. Re-Certification     OSHA Mandated Specify Return to Work Evaluation     Other Specify Industrial Injury Care Post-Accident Drug Screen Post-Accident Alcohol Testing Special Testing PFT/Pulmonary Function Test     Respirator Fit Testing     Audiometric Testing     Lab Test Specify Other Comments, Questions or any other information