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Get Employee Appointment Form

Print Form Kaiser On-the-Job Appointment Request Company Name Employee Kaiser Medical Record Number Do NOT include number. Yes No Employee Name First Middle Last Maiden Name or Previous Name s Date of Birth Male Female Phone Home Address Street City ZIP Appointment Preference Date Time Interpreter Needed Language Services Requested Check type of exam/testing Post-offer/Pre-placement exam DMV Fitness for Duty Periodic/Annual Exam Medical Surveillance/Additional Testing Functional Capacity Exam At Kaiser Outside Kaiser PPD Immunization Hearing audiogram Hazardous Waste Worker/HAZMAT Urine Drug Screen BAT Pre-placement Random Reasonable suspicion Lead With ZPP Respiratory Will employee be using SCBA Yes No Asbestos Includes respiratory spirometry chest x-ray Other Sepcify Additional instructions Job Class Department Contact Person Fax Employee Supervisor Name Clearance to be faxed to Name Fax Number Please indicate preferred clinic for treatment Santa Rosa Clinic 3975 Old Redwood Highway Santa Rosa CA 95403 Phone 707 566-5550 Fax 707 566-5536 www. kaisersantarosa*org/ohs Rohnert Park Clinic 5900 State Farm Drive Rohnert Park CA 94928 Phone 707 206-3091 Fax 707 206-3093. Yes No Employee Name First Middle Last Maiden Name or Previous Name s Date of Birth Male Female Phone Home Address Street City ZIP Appointment Preference Date Time Interpreter Needed Language Services Requested Check type of exam/testing Post-offer/Pre-placement exam DMV Fitness for Duty Periodic/Annual Exam Medical Surveillance/Additional Testing Functional Capacity Exam At Kaiser Outside Kaiser PPD Immunization Hearing audiogram Hazardous Waste Worker/HAZMAT Urine Drug Screen BAT Pre-placement Random Reasonable suspicion Lead With ZPP Respiratory Will employee be using SCBA Yes No Asbestos Includes respiratory spirometry chest x-ray Other Sepcify Additional instructions Job Class Department Contact Person Fax Employee Supervisor Name Clearance to be faxed to Name Fax Number Please indicate preferred clinic for treatment Santa Rosa Clinic 3975 Old Redwood Highway Santa Rosa CA 95403 Phone 707 566-5550 Fax 707 566-5536 www. kaisersantarosa*org/ohs Rohnert Park Clinic 5900 State Farm Drive Rohnert Park CA 94928 Phone 707 206-3091 Fax 707 206-3093.

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