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Forms
At U.S. HealthWorks, we understand that you want to use your time efficiently. To accomodate your needs, you can access the following forms so that they can be filled out prior to your visit to one of our medical centers.
WORK RELATED: EMPLOYER TREATMENT AUTHORIZATION & EMPLOYEE/PATIENT IN-TAKE FORMS
Prior to an employee being treated at one of our medical centers, we request that a Treatment Authorization form be filled out by the employer. This form should be brought in by the employee at the time of service. If a drug screen and/or BAT is required in addition to medical treatment, please indicate this on the Treatment Authorization form (for a drug screen/BAT only, see below "Drug Screen and Breath Alcohol Testing In-Take Forms").
We have also included patient in-take forms to be filled out by the employee which
will assist in the registration process. The employee may choose to fill out these
forms prior to arriving at one of our medical centers or they will be provided to the employee by our front desk. If an employee is being sent for a flu shot, we have also made available the Influenza Vaccine Consent Form.
For EMPLOYERS to fill out (work-related):
For EMPLOYEE/PATIENT to fill out (work-related):
DRUG SCREEN AND BREATH ALCOHOL TESTING IN-TAKE FORMS
Below you will find forms that employers, employees and non-work related patients will be required to fill out prior to a drug screen and breath alcohol test.
Prior to an employee being sent to our facilty for a drug screen/alcohol test, we request a Treatment Authorization form be filled out by the employer. This form should be brought in by the employee at the time of service.
We have also included patient in-take forms to be filled out by the employee which will assist in the registration process. The employee may choose to fill out these forms prior to arriving at one of our medical centers or they will be provided to the employee by our front desk.
For EMPLOYERS to fill out:
For EMPLOYEE/PATIENT to fill out:
For NON-WORK RELATED Drug/Alcohol screen to fill out:
NON-WORK RELATED: URGENT CARE PATIENT IN-TAKE FORMS
If you are a new Urgent Care (non-work related) patient who will be utilizing the services of a U.S. HealthWorks center, you will be required to fill out these forms. The completed forms will be stored in your personal records and referenced for future visits. You may choose to fill out these forms prior to arriving at one of our
medical centers or they will be provided to you by our front desk staff before
being treated.
If you are visiting one of our centers for a flu shot we have also made available the Influenza Vaccine Consent Form.
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