Make An Appointment
Client Service Authorization
Employer Name
Store Number
Authorized By
Title
Telephone (8165611025)
Appointment Date (mm/dd/yyyy)
Patient
Clinic Location
Blue Springs, Missouri
Downtown Kansas City, Missouri
Independence, Missouri
Northeast Kansas City, Missouri
St. Joseph, Missouri
Kansas City, Kansas
Lenexa, Kansas
Grandview, Missouri
Worker's Compensation Injury
Authorization to treat work comp injury until resolved or notified by employer designee to no longer treat the patient
Treat initial visit only (further treatment requires additional authorization)
Treat previously closed case until otherwise notified
Date Of Injury (mm/dd/yy)
Drug Testing on initial?
Yes
No
Other Information
Physical Examinations
DOT Initial
Return to Duty
DOT Recertification
Fit for Duty
Asbestos
Respiratory Physical
Initial
Periodic
Initial
Periodic
Hazardous Materials
Basic Preplacement
Physical
Initial
Periodic
Other
Drug and Alcohol Screening
Urine Drug Testing;
Please choose Type:
Non-DOT (NonRegulated) or
DOT (Regulated)
Pre-placement
Post Treatment
Post Accident
Reasonable Suspicion
Random
Breath Alcohol Testing;
Please choose Type:
Non-DOT (NonRegulated) or
DOT (Regulated)
Post Accident
Reasonable Suspicion
Random
General Liability Injury Care
Date of Injury:(mm/dd/yyyy)
Insurer:
Contact:
Contact Phone:(8165611025)
Other
Hepatitis B Vaccine
Skills Agility Testing
TB Test with X-Ray as Indicated
Comments:
Physical Capacity Testing
Requested Date:(mm/dd/yyyy)
Time:(hh:mm)
24-hour clock
"POET" requires work site analysis and approved protocols for more information contact Client Services at 816-561-2105
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