AUTHORIZATION FOR TREATMENT
Work Injury Treatment
- (indicate drug screen to right)
Physical – Post Offer
Physical – Return to Work
Physical – DOT / DMV
Respirator Fit Test
Audio / Hearing Test
PPD – TB Test
Other:
Employer: _______________________________
Department / Division: _____________________
Supervisor: ______________________________
Contact Phone: ___________________________
Drug Screen to Perform or Include:
(required)
____________________________________________________
Open 24 Hours a Day - 7 Days a Week
LAX Airport Area
5901 W Century Blvd
Los Angeles, CA 90045
310-215-6020
Huntington Park
5900 Pacific Blvd
Huntington Park, CA 90255
310-491-7080
Downtown Los Angeles
814 S Francisco St
Los Angeles, CA 90017
310-491-7070
Directions & Maps
www.ReliantUrgentCare.com
Montebello
2300 Beverly Blvd
Montebello, CA 90640
626-467-0202
Santa Fe Springs
11460 Telegraph Rd
Santa Fe Springs, CA 90670
310-491-7060
5 Panel
DOT
eScreen 5 Panel
BAT
Do NOT Perform Drug Screen
10 Panel
Non DOT
eScreen 10 Panel
Post Accident
Follow-Up
Pre-Employment
Return to Duty
Random
Reasonable Suspicion
Authorized By:
Authorized By:
__________________________________
____________________________________________________
Employee Information:
Employee: ________________________________
Employee ID / Badge: _______________________
Date of Injury: _____________________________
Requested Services:
Work Injury or Physical:
____________________________________________________
Reason for Drug Screen:
(required if DS ordered)
Today's Date & Time: _______________________
Print Form
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