Employee Name*: SSN*: Injury Date & Time:* Fax #*: Person Authorizing Treatment (Print Name)*: Phone # of Authorizing Person*: Check all that apply: Coast Guard PhysicalNon-DOT PhysicalDOT PhysicalWorker’s Comp. InjuryTB Skin TestEKG Immunizations (TDAP, Hep A, Hep B, Tetanus/Diptheria, Flu, etc.)Respirator Clearance Exam with PFTLift TestAudiogramWeigh InChest X-RayWorker’s Comp. InjuryAgility TestLab Testing (CBC, CMP, Urinalysis, LIPID Profile, HIV, etc.)Chest X-RayVision TestL-Spine X-Ray Other Testing Information: Type Non-DOT Urine Drug ScreenDOT Urine Drug ScreenDOT Urine Drug ScreenHair CollectionRapid/Onsite Urine Drug Screen5 Panel10 Panel Reason Pre-EmploymentPeriodicRandomFor Cause / SuspicionPost AccidentFollow upReturn to Work Special Instructions Emergency Instructions: Life or Limb- Threatening Injuries – Dial 911 Non-Life or Non-Limb- Threatening Injuries – Dial (985) 645-9000 Follow-up care for an injury – Dial (985) 645-9000