Occupational Medicine Patient Registration
Time Elapsed:
0
minutes
Time Remaining:
0
minutes
Total Time:
0
minutes
Anonymous Login Code:
Code Entry Page
Save this code which is required to update your response at a later time.
Occupational Medicine Patient Appointment Registration
(Fields marked with an * are required.)
Date:
Appointment type:
Exams/Contract Services
Work Injury Care
Other, please specify
Company/Employer:
*
Preferred clinic:
*
-- Please Select --
Bridgeport
Clackamas
Hood River
Medford
Mill Plain
Newberg
Plaza
Tanasbourne
Next Available
Preferred appointment time:
Next available
Morning
Afternoon
Job Title:
*
(Please Specify)
Services Requested
EXAM SERVICES:
Services:
Pre-placement
DOT Exam New
DOT Exam Recert
Bus Driver Exam New
Bus Driver Exam Recert
Medical Surveillance Exam- Baseline
Medical Surveillance Exam- Periodic
Medical Surveillance Exam- Exit
Firefighter Exam
Police Officer Exam (DPSST)
Respirator Exam
Other Exam
Optional Services (Please Specify)
ANCILLARY SERVICES:
Audiogram
Baseline
Annual
Respirator Fit Test
TB Skin Test
Immunization
Antibody Testing
Other, please specify
SUBSTANCE TESTING:
Reason for visit:
(Please check one)
Pre-placement
Random
Post-accident
Reasonable suspicion
Follow-up For cause
Return to duty
DOT (FMCSA)
DOT (PHMSA)
DOT (USCG)
DOT (FTA)
DOT (FAA)
DOT (FRA)
Non-DOT
Express/Rapid
Breath alcohol test - DOT
Breath alcohol test - Non-DOT
Direct observation required
Other, please specify
Full Legal Name:
*
First Middle Name Last
Employee ID Number:
(optional)
Gender:
Male
Female
Date of Birth:
Social Security Number:
(optional)
Address:
City:
State:
Zip:
Primary Phone:
*
Email: