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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*
Services:
1. Physical Exam
2. Urine Drug Screen
3. DOT Breath Alcohol Test
4. Non-DOT Saliva Alcohol Test
5. On-the-Job (Workers' Comp) Injury Evaluation
6. Other Services
Physical Exam:
1. DOT
2. Respiratory
3. Fit for Duty
4. Police
DOT or Non-DOT Urine Drug Screen?
Reason for Test:
Other Services:
Additional Notes:
Authorized By:
Title
Phone