Occupational Medicine Services Request form

                      EXPRESS CARE OF TAMPA BAY, iNC.

      Pre Employment Services          (Check  mark all that is needed)                       Immunizations / Shots

 Occupation related Physical Exams ( CHECK MARK REQUESTED SERVICES)

  Work related Injury treatment:

  This is Work comp initial visit*            *Please provide 1st Notice of injury with the employee/patient.

        Drug Test required              Drug Test not required         Bill Company    Bill insurance carrier

    This is a  Work Comp follow up from ER      Please provide Hospital records with your visit to save time

     This is a  Work comp follow up visits       

         NOTE : WE NEED THE ABOVE  WORK COMP INFORMATION ONLY ON THE FIRST VISIT.

Note to Employers: Please select the appropriate services requested above. Please sign and date this authorization 

form and send or fax it to us prior to patients arrival at the clinic.

Today's Date; ____________ Authorized By: ______________________   Signature: ____________________

Company's Name; ________________________ Billing address : _______________________ City:____________ St: ___

Telephone # __________________      Fax # ____________________   Insurance carrier info:________________________ 

Address______________________________________________________________________________________________

Policy #__________________ Phone # ______________  Case Manager: ____________________________

                                           Fax it to: EXPRESS CARE at 813-645-3816 Apollo Beach

                                                   OR  EXPRESS CARE at 813-                     BRANDON