OccuCare

Authorization for Examination and/or Treatment
Employer:		Authorized by:
First Name:	Last Name:		M.:
Address:
City:	State:		ZIP:
SS:	Date of Birth:		Age:
Phone:	Cell:	Driver License #:
Medication Allergies:
I consent to release any test results and other relevant medical information to the authorized company management for appropriate review. I understand and I have the right to refuse to consent.
Bill Company Bill Carrier
Work Related Injury	TB Skin Test PPD		Drug Screen
Physicals	Audiogram		Regular
Employment	X-Ray		Rapid
D.O.T.	Travel Immunizations		Hair Sample
Fit For Duty	EKG		D.O.T.
Annual	Pulmonary Function Test		B.A.T./Q.E.D.
Return to Work	Respirator Fit Test		Laboratory
Oil & Gas UK	Stress EKG		Other
Respirator