Precision Medical and Occupational Health by sgs479i

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									                    Precision Medical and Occupational Health
                    Five Atkinson Drive, Suite 302, Ludington, MI 49431 (231) 843-6200

                        Rodney L. Kilpatrick, D.O., Medical Director

                                        Client Demographics

Company Name ____________________________________________ # of employees ____________

Address ________________________________ Telephone __________________________________

_______________________________________ Dedicated HR Fax ____________________________

Primary Designated Employer Representative _________________________ Phone _______________

Alternate Employer Rep __________________________________________ Phone _______________

Work Comp Carrier __________________________________ Contact _________________________

Address ___________________________________ Toll Free Phone (if available) ________________

__________________________________________ Fax _____________________________________

Primary Case Manager ______________________________ Direct Phone _______________________
                                                    Direct Fax _________________________
Alternate Case Manager ____________________________ Direct Phone ________________________
                                                    Direct Fax __________________________
Notes _______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Company Preferences
Do you have a pre-employment/post accident drug screen policy in place? ____ Yes ____ No

Pre-Placement Exams Tier 1 ____ Tier 2 ____ Tier 3 ____ Dot ____ Other _______________________

Back Stability Exam ____ Lift Testing 25# ____ 40# ____ 50# ____ Other # ____

X-rays _____________________________

Laboratory Tests
       Urine Drug Screen 10 panel ____ 5 panel DOT ____ DSC ____ Other ______________

              Pre-Employment ____ Post-Accident ____ Reasonable Suspicion ____

       Breath Alcohol         DOT ____ Non DOT ____

              Pre-Employment ____ Post-Accident ____ Reasonable Suspicion ____

       Other Labs _____________________________________________________________

Other Tests

Audio ____ Respiratory Certifications ____ PFT ____ EKG ____ Fit Test ____

								
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