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City of Rockville - Authorization of Services - Patriot
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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
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