Employer Request For Treatment

Company

Manager Name

Employer Address

Employer Phone

Employer Fax

WC Ins. Policy #

WC Ins. Address

WC Ins. Phone:

Modified WK Available?
No Yes

Service Requested
New Injury
Spirometry PFT
NIDA Drug
Return To Work
PPD (TB Test)
Non-NIDA Drug
Pre-Emp Phys
Chest X-Ray
Breath Alcohol
DMV Physical
Hepatitis B Vac (Photo Required)
Audiometry
Other:

Preferred Location
Valley
Glendale
Bakersfield
Delano