Employer Authorization

Employee Name *

First Name

Last Name

Date of Service

MM

DD

YYYY

Phone *

(###)

###

####

Physical

Non-DOT

DOT (CDL)

Coast Guard

Agility

Functional Capacity

Breath Alcohol

Non-DOT

DOT

Drug Screen

Non-DOT (Our house account)

DOT (Our house account)

Coast Guard (Our house account)

Collection Only (Your COC or Formfox)

Hair Collection

Oral Collection

Instant 10

Instant 12

Reason for Testing

Pre-Employment

Random

Reasonable Suspicion

Post Accident

Follow-Up

Return to Duty

Testing Agency (FOR DOT DRUG SCREENS ONLY)

FMCSA

FAA

FRA

FTA

PHMSA

Other (Specify in box below)

Fit Test

Qualitative (Specify mask in box below)

Other Services

TB Skin Test

QuantiFERON TB Gold

T-SPOT

EKG

Urinalysis

TDAP Vaccine

Flu Vaccine (Seasonal)

Chest Xray

L-Spine Xray

Vision Acuity (Snellen)

Color Vision (Ishihara)

Bloodwork (Specify test(s) in box below)

Other service (Specify test(s) in box below)

Work Injury

Injury Visit