open 24 hours a day - 7 days a week - reliant …...los angeles, ca 90045 310-215-6020 huntington...
TRANSCRIPT
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: _______________________