Skip to Main Content
Loading
Close
Loading
Alert
Monday, May 23 Mayor and Council Meeting to Be Virtually Only
Read On...
About Rockville
City Government
City Projects
Services
Form Center
Form Center
Welcome to the City of Rockville Form Center. If your form requires a response, we will contact you as soon as possible.
Search Forms:
Search Forms
Select a Category
All Categories
City Clerk
City Manager
Claims
Code Enforcement
Community Planning and Development Services
Finance
Housing Programs and Services
Human Resources
I-Rock
Police
Public Works
Recreation and Parks
Report a Concern
Volunteering
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
City of Rockville - Authorization of Services - Patriot
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Patriot Urgent Care
Date of Arrival
*
Date of Arrival
Employee Name:
*
Facility
*
-- Select One --
Rockville
Germantown
Laurel
Services:
Physical Exam
Urine Drug Screen
DOT Breath Alcohol Test
Non-DOT Saliva Alcohol Test
On-the-Job (Workers' Comp) Injury Evaluation
Other Services
Physical Exam:
DOT
Respiratory
Fit for Duty
Police
DOT or Non-DOT Urine Drug Screen?
-- Select One --
DOT
Non-DOT
Reason for Test:
-- Select One --
Pre-Employment
Post-Accident
Return to Duty
Random
Reasonable Cause
Follow-up
Other Services:
Additional Notes:
Authorized By:
Title
Phone
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
* indicates a required field
Departments
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow