AUTHORIZATION FOR TREATMENT Work Injury Treatment - (indicate drug screen to right) Physical – Post Offer Physical – Return to Work Physical – DOT / DMV Respirator Fit Test Audio / Hearing Test PPD – TB Test Other: Employer: _______________________________ Department / Division: _____________________ Supervisor: ______________________________ Contact Phone: ___________________________ Drug Screen to Perform or Include: (required) ____________________________________________________ Open 24 Hours a Day - 7 Days a Week LAX Airport Area 5901 W Century Blvd Los Angeles, CA 90045 310-215-6020 Huntington Park 5900 Pacific Blvd Huntington Park, CA 90255 310-491-7080 Downtown Los Angeles 814 S Francisco St Los Angeles, CA 90017 310-491-7070 Directions & Maps www.ReliantUrgentCare.com Montebello 2300 Beverly Blvd Montebello, CA 90640 626-467-0202 Santa Fe Springs 11460 Telegraph Rd Santa Fe Springs, CA 90670 310-491-7060 5 Panel DOT eScreen 5 Panel BAT Do NOT Perform Drug Screen 10 Panel Non DOT eScreen 10 Panel Post Accident Follow-Up Pre-Employment Return to Duty Random Reasonable Suspicion Authorized By: Authorized By: __________________________________ ____________________________________________________ Employee Information: Employee: ________________________________ Employee ID / Badge: _______________________ Date of Injury: _____________________________ Requested Services: Work Injury or Physical: ____________________________________________________ Reason for Drug Screen: (required if DS ordered) Today's Date & Time: _______________________