<p> Occupational Health Services Authorization and Referral Form</p><p>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</p><p>COMPANY: ______</p><p>EMPLOYEE NAME: ______</p><p>DATE: ______TIME: ______</p><p>EMPLOYEE MUST BRING A PHOTO I.D.!</p><p>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</p><p>□ Breath Alcohol Testing ___ Pre-Placement ___ Return to work ___ Reasonable Suspicion/Cause ___ Post Accident ___ Random</p><p>□ Drug Testing ___ Pre-Placement ___ Return to work ___ Reasonable Suspicion/Cause ___ Post Accident ___ Random ___ Periodic □ Other ______</p><p>AUTHORIZED BY: Name: ______Title: ______Phone: ______Special Instructions: ______</p><p>PLEASE GIVE FORM TO RECEPTIONIST UPON ARRIVAL Rocky River Urgent Care 19895 Detroit Road Rocky River, Ohio </p><p>Ridge Park Urgent Care 7580 Northcliff Avenue Suite 700# Brooklyn, Ohio 44144</p>