Patient's Name *
 Company Name
Authorizing Person
 Phone *
Service(s) Requested
Work Related Injury    Return to Work Evaluation   
Drug Screen--5 Panel (DOT regulated)    Drug Screen--9 Panel (non-DOT regulated)   
“Quick” Drug Screen    “eScreen” Drug Screen   
Breath Alcohol Test    DOT Physical   
General Physical    Annual Medical Surveillance Exam   
Physical Abilities Testing    Daycare Physical   
Teacher Physical    TB Skin Test/PPD   
Pulmonary Function Test    Audiogram   
Hepatitis B Vaccine    Hepatitis B Titer/Blood Test   
Travel Medicine Services    Flu Shot   
Other Services or Instructions

Privacy Statement:
The information which you give in completing this form will be forwarded to the designated party for its use and will not be used by Real Pages for any other purpose or provided by us to any other parties.  If you wish information concerning the privacy policy or the designated recipient, you should contact them directly.

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