EMPLOYMENT PHYSICALS AND SCREENING DOT Physical Post-Offer Physical (Non-DOT) Return to Work Merchant Marine / USCG Law Enforcement/Fire Fighter Flight physical (FAA) Comprehensive/HazMat Respiratory Certification Exam Audiology Vision EKG Other _______________________ _______________________________ IMMUNIZATIONS Type(s): _________________________________________________________ OCCUPATIONAL INJURY AND ILLNESS CARE Serious injuries call 911 or go directly to the Emergency Room. After hours injury care is available at MultiCare Urgent Care Centers and Emergency Rooms. Urgent Care Centers and Emergency Rooms do not perform drug testing. Call the on-call collector (below) New injury - Walk-ins welcome Follow-up injury care - Call for appt. CHECK ALL SERVICES REQUIRED Date Employee/Patient Name Job Position Remarks & Requirements Company Contact Signature Date Employer contact complete or staple business card here Company Name Address City, ST, Zip Contact Name Contact Telephone Contact Fax Contact email AUTHORIZATION - REFERRAL multicareoccmed.org Serious injuries call 911 or go directly to the Emergency Room After hours injury care is available at MultiCare Urgent Care Centers & Emergency Rooms. For Urgent Care locations visit www.multicare.org/urgent-care/ MultiCare Allenmore Medical Center Emergency Dept. 1901 S. Union Ave, Tacoma, WA 98405 MultiCare Auburn Medical Center Emergency Dept. 202 No. Division St. Auburn, WA 98001 MultiCare Covington Emergency Dept. 17700 SE 272nd St., Covington, WA 98042 MultiCare Good Samaritan Hospital Emergency Dept. 401 5th Ave SE, Puyallup, WA 98372 MultiCare Tacoma General Hospital Emergency Dept 315 Martin Luther King Jr Way, Tacoma, WA 98405 Rev.04/15 MultiCare Occupational Medicine - Kent 222 State Ave N Kent, WA 98030 p 253.545.5970 in the main MultiCare Kent Clinic MultiCare Occupational Medicine - Fife 502 54th Ave E Fife, WA 98424 p 253.459.7569 Corner of 54th Ave E and 4th St E MultiCare Occupational Medicine - Auburn 202 Cross St SE Auburn, WA 98002 p 253.876.8140 at MultiCare Auburn Health Center MultiCare Occupational Medicine - Tacoma 3124 S. 19th St #110 Tacoma, WA 98405 p 253.459.6658 1st Floor, Building C at Allenmore Medical Center MultiCare Occupational Medicine - Puyallup 1450 5th St SE #1500 Puyallup, WA 98372 p 253.697.4014 1st Floor, Good Samaritan Medical Office Building MultiCare Occupational Medicine - Lakewood 5700 - 100th St. SW #510 Lakewood, WA 98499 p 253.459.6005 Near Lakewood Town Center in the Lakewood Pavilion LOCATIONS HOURS: Mon-Fri 8am - 4:30pm FOR APPOINTMENTS: 888.280.5513 OPT 1 Employee/Patient MUST provide photo ID for all services. Please do not bring children requiring supervision to the clinic. DRUG & ALCOHOL TESTING Walk-ins welcome. No unaccompanied minors DOT Urine Drug Test Non-DOT Urine Drug Test EBT/Breath Alcohol Test Other: ______________________ _______________________________ Pre-employment Random Reasonable Suspicion / For Cause Post-accident or Injury Return to Duty Follow-up After-hours drug & alcohol testing is available in some areas for post-injury/ accident and reasonable suspicion. Call 253.327.4420 to reach the on-call collector. Please call ahead for walk-in visits as hours occasionally vary.