Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Enter the employer's name in the designated field at the top of the form.
3. Indicate whether the employee is from a staffing agency by selecting 'Yes' or 'No.' If 'Yes,' provide the name of the agency.
4. In the 'Authorized By' section, print and sign the name of the authorized individual.
5. Fill in the employee's name and address in the appropriate fields.
6. Provide the employee's social security number, email, and date of birth.
7. Select the reason for the visit by checking all applicable boxes, such as 'Work Related,' 'Physical Examination,' or 'Substance Abuse Testing.' Be sure to include any relevant details, such as the date of occurrence and affected body part for injuries.
8. If applicable, fill in details regarding substance abuse testing. Specify the type (DOT or Non-DOT) and the reason for testing.
9. Complete any additional procedures that apply, including immunizations or specialized tests.
10. If required, indicate if the employee is responsible for paying charges by checking the billing box.
11. Finally, include any specific instructions or comments in the designated area.
12. Review all entries for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your forms online today for an efficient and streamlined process!