Forms

Answers to questions about care

Your time is valuable. WORKNET understands that and strives for punctuality with its appointments. Completion of the following forms and other required documents prior to scheduled visits helps our providers stay on schedule and complete services without delay.

Walk in visits for new injuries, drug screens and purified protein derivative (PPD) tests are expected. However, scheduled appointments for physicals and follow-up appointments are preferred and receive priority. Providing your employees with forms ahead of time will help us provide a better employee/patient experience.

Authorization and consent on behalf of a minor form

DOT forms:

Patient registration
DOT medical examination report form MCSA 5875
DOT insulin treated diabetes mellitus assessment form MCSA 5870
School bus physical

OSHA-required medical surveillance:

Patient registration
OSHA respirator questionnaire
OSHA respirator questionnaire (Spanish)
Asbestos questionnaire initial evaluation
Asbestos questionnaire periodic evaluation
Respirator/hazmat potential exposure data form
Audiogram test form and record

Employer forms:

Patient registration
Authorization and request for medical services

Drug and alcohol:

Consortium list update form