HOLLAND MEDI CENTERAUTHORIZE TO TREAT FORMPrintable Authorize to Treat FormCompany / Organization Name*Company / Organization Phone*Authorized By Name*Authorizer Phone*Submitter Email* Employee InformationEmployee Name* First Last Employee Date of Birth Employee Phone*Employee Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country INJURYTreatment/Evaluation Drug Screen with initial visit Breath Alcohol TestDOT ProceduresPhysical ExaminationSelect OneNewRecertificationFollow-upDrug Test - Federally MandatedSelect OneUrineReason For Drug TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upDOT - Specify DOT AgencySelect OneFMCSAFTAFAAPHMSAFRAUSCGAlcohol Test - Federally MandatedSelect OneBreath Alcohol TestReason For Alcohol TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upNon-DOT ProceduresPhysical ExaminationSelect OnePost Offer/Pre-employmentReturn to WorkFit for DutyRespiratoryHazmatAsbestosOtherDrug Test - Type Pre-established Protocol (HMC Clients) Test @ HMC-rapid screen Collection ONLY-Urine Hair Collection Saliva Direct ObserveDrug Test Protocol*Select One610NicotineReason For Drug TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upAlcohol Test - TypeSelect OneBreath Alcohol TestReason For Alcohol TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upOtherOther test options Chest X-Ray Pulmonary Function Test Audiogram baseline Vision Titmus Respirator Fit Test Tetanus Audio Annual Vision Ishahara Audio Follow-up Vision Jaeger LabsLab details* Hepatitis B VaccineVaccine Number* Tuberculosis (TB)TB Testing Options*1 Step2 Step TiterTiter Type* Lift test & educationNumber*Other InstructionsCompany instructions: Other testing and/or company specific instructionsNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.