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Get TX MedClinic Treatment Authorization

Eatment (please print): Employee name: Social Security #: DOB: Time: Authorization expires on: Date: Clinic Location: (Please select a Location) SERVICES REQUESTED MEDICAL EVALUATION - DRUG/ALCOHOL TESTING Work related injury treatment Post Offer Physical* Health Screening Assessment** DOT Physical Asbestos Physical Initial Periodic Hazardous Waste Physical Respirator Physical Respirator Fit Test PFT (Spirometry) Audiometry TB test Check here if chest x-ray is authorized Other: IMMUNIZATIO.

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