Dear Client:

Thank you for selecting Tri-Industrial Medical Center, Inc. as your industrial medical provider for your worker's compensation injuries, D.O.T., pre-placement, and annual physical examinations and drug screens.

Please help us to serve you more efficiently by completing the following information.


Form:

Company Phone
Address
Nature Of Business No# Employees
Modified Duty Available: Yes         No
Hrs of Operation AM   PM Days of Week
Primary Contact 2nd Contact
Evening Phone Contact
Other Contacts
Return Appointments: During Shift After Shift
Special Instructions
Safety Manager Phone:

Computer Registration Form   Co. Account #
Workers' Compensation Insurance Carrier Information:
Carrier Policy#
Address Phone
City State Zipcode
Claims Adjuster:
Special Instructions:

Pre-Placement/Annual Examination Requirements
Please Check tests required:

History & Physical D.O.T Physical
Audiogram D.O.T Drug Screen
Back X-Ray Breath Alcohol
Chest X-Ray Random Drug Screen
Urinalysis (Lab) CBC
Spirometry EKG
Non-D.O.T Drug Screen Other
Total
Special Instructions

Drug Screen Report to Be released only to:

1.
2.
3.


I hereby agree/authorize Tri-Industrial Medical Center, Inc. To treat the employees of for work related injuries./illness including all test.exams indicated above. I also am aware of and understand that my company is fully responsible for all charges incurred for treatment to all employees that we refer to Tri-Inudstrial Medial Center, Inc.


Company Representative Title Date

 

 

 

 

 

About Us |Meet Doctors & Staff | Drug Screening | Industrial Accidents | Employment DOT Physicals |
Physical Occupational Therapy | Home | Contact | Site Map

At Tri- Industrial Medical, a full service industrial medical clinic, our services include pre-employment D.O.T. physicals, random drug screening programs,
breath alcohol testing, physical and occupational therapy, as well as handling industrial accidents claims.


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