Occupational Health Services Authorization and Referral Form

Ridge Park Urgent Care Rocky River Urgent Care 7580 Northcliff Avenue Suite 700 19895 Detroit Road Brooklyn, Ohio 44144 Rocky River, Ohio 44116 Phone: 440-886-1800 Phone: 440-356-5500 Fax: 216.741.8525 Fax: 440.356.9585 Monday-Friday 8am-8pm Monday-Friday 8am-9pm Saturday-Sunday 9am-5pm Saturday-Sunday 9am-6pm

COMPANY: ______

EMPLOYEE NAME: ______

DATE: ______TIME: ______

EMPLOYEE MUST BRING A PHOTO I.D.!

Indicate services to be performed. □ Treatment for work related injury or illness. Date of injury: _____ □ Physical Examinations ___ Pre-Placement ___ Return to work ___ OSHA-Medical Surveillance ___ DOT ___ Respirator Fitness

□ Breath Alcohol Testing ___ Pre-Placement ___ Return to work ___ Reasonable Suspicion/Cause ___ Post Accident ___ Random

□ Drug Testing ___ Pre-Placement ___ Return to work ___ Reasonable Suspicion/Cause ___ Post Accident ___ Random ___ Periodic □ Other ______

AUTHORIZED BY: Name: ______Title: ______Phone: ______Special Instructions: ______

PLEASE GIVE FORM TO RECEPTIONIST UPON ARRIVAL Rocky River Urgent Care 19895 Detroit Road Rocky River, Ohio

Ridge Park Urgent Care 7580 Northcliff Avenue Suite 700# Brooklyn, Ohio 44144