AUTHORIZATION FOR TREATMENT

Work Injury Treatment- (indicate drug screen to right)

Physical – Post OfferPhysical – Return to WorkPhysical – DOT / DMVRespirator Fit TestAudio / Hearing TestPPD – TB TestOther:

Employer: _______________________________

Department / Division: _____________________

Supervisor: ______________________________

Contact Phone: ___________________________

Drug Screen to Perform or Include: (required)____________________________________________________

Open 24 Hours a Day - 7 Days a Week

LAX Airport Area5901 W Century BlvdLos Angeles, CA 90045310-215-6020

Huntington Park5900 Pacific BlvdHuntington Park, CA 90255310-491-7080

Downtown Los Angeles814 S Francisco StLos Angeles, CA 90017310-491-7070

Directions & Mapswww.ReliantUrgentCare.com

Montebello2300 Beverly BlvdMontebello, CA 90640 626-467-0202

Santa Fe Springs 11460 Telegraph Rd Santa Fe Springs, CA 90670 310-491-7060

5 PanelDOTeScreen 5 PanelBATDo NOT Perform Drug Screen

10 PanelNon DOTeScreen 10 Panel

Post AccidentFollow-UpPre-Employment

Return to DutyRandomReasonable 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: _______________________