Occupational Health Authorization for Treatment
Date
Patient Name
Social Sec #
Duties Performed / Type of Work
Employer
Name of Person Authorizing Treatment
Phone #
Special Instructions
Type of Service to be Provided
Injury or Illness Care
Return to Work Evaluation
Include Post-accident drug screen
Pre-placement / Post-offer Physical Exam
Fitness for Duty Evaluation
Include Pre-placement drug screen
DOT Physical Exam
Audiogram
Pulmonary Function Test
Include DOT drug screen
Drug Screen Only (choose one):
Pre-employment
Random
Reasonable Suspicion
Post-accident
Other
COMPANY
DATE
Chart
DIAGNOSIS
PHYSICIAN SIGNATURE
WORKER COMPENSATION DISCHARGE INSTRUCTIONS
:
These guidelines have been prepared to aid in your care. If you fail to improve, become worse, or have problems, please return to Playa Vista Occupational Medicine or Marina del Rey Hospital emergency department (after 8:00pm) be rechecked or to see your doctor.
The following orders apply to you:
Bed rest as needed
No weight bearing on injured leg (see Crutch Walking sheet)
Ice for 20 minutes 3-4 times daily
Raise the injured part
Keep dressing clean and dry (see Wound sheet)
Watch for signs of infection (fever, redness, drainage)
Return for recheck on
(Date) between 8:00 am and 800 pm
Moist heat
Times daily
FOLLOW UP
Referred to
Appointment date / time
I have read and understand the above instructions. It is my responsibility to give this form to my employer and inform him/her of my illness/injury.
Patient Date Witness * Separate Discharge Instruction Sheet