Clinic Locations - North Memorial Health Care

www.northmemorial.com
Occupational Medicine
I hereby authorize (employee name) __________________________________ to receive the indicated services
below on behalf of (company name) _________________________________________. (Check all services needed below)
 Work Related Injury or Illness Treatment
 Work Related
 Undetermined
 Post-Accident Drug Screen Required  Breath Alcohol Test Required
Drug Screening (check both “Test Type” and “Reason for Test”)
Test Type:




 DOT FMCSA FTA PHMSA Other
 Non-DOT
 Non-DOT Rapid
 Hair
Reason for Test:
 Pre-employment
 Random
 Post-Accident
 Return to Duty (observed)
 Follow-Up (observed)
 Reasonable Suspicion
 Employee responsible for payment at time of service
Breath/Blood Alcohol Testing (check both “Test Type” and “Reason for Test”)
Test Type:



 DOT- Breath
 Non-DOT - Breath
 Non-DOT - Blood Alcohol

Reason for Test:
 Pre-employment
 Random
 Post-Accident
 Return to Duty
 Follow-Up
 Reasonable Suspicion
 Employee responsible for payment at time of service
Exams
 DOT Medical Card
 General Employment
Position _________________
 Job Description Attached (recommended)
 Lift Analysis (up to 75lbs.)
 Other ________________________
 Respiratory Medical Clearance
 Asbestos Medical Clearance
 Back Evaluation
 Back with Extremity Evaluation
 Positive/Past-Positive Tuberculin Exam/X-Ray
 Employee responsible for payment at time of service
Other
 Lead & ZPP Blood Draw
 Hepatitis B Vaccination
 Tuberculin Skin Testing (TST)/Mantoux
 Tetanus Shot
 Titer _______________________
 Other ______________________
 Employee responsible for payment at time of service
Manager or Supervisor information required
Date ___/___/_____
Printed Name________________________________________ Phone ____________________
Signature______________________________________________________ Notification Time _______________________
1/31/14 Brev
www.northmemorial.com
Occupational Medicine
Clinic Locations:
North Memorial Clinic
Elk River
North Memorial Clinic
Golden Valley
800 Freeport Ave NW Ste. 100
Elk River, MN 55330
P: 763-581-5200
F: 763-581-5221
Mon-Sun, 8:00 am- 8:00 pm
8301 Golden Valley Rd. Ste. 100
Golden Valley, MN 55427
P: 763-581-5150
F: 763-581-5158
Mon-Fri, 7:00 am-5:00 pm
Sat–Sun. CLOSED
North Memorial Clinic
Minneapolis-Camden
North Memorial Clinic
Ridgedale
(Appointments preferred for exams)
4209 Webber Pkwy
Minneapolis, MN 55412
P: 763-581-5750
F: 763-581-5751
Mon-Fri, 8:00 am - 5:00 pm
Sat–Sun, CLOSED
2000 Plymouth Rd. Ste. 100
Minnetonka, MN 55305
P: 763-581-5250
F: 763-581-5285
Mon-Fri, 8:30 am - 5:00 pm
Sat–Sun, CLOSED
North Memorial Urgent Care
Roseville
North Memorial Mobile
1955 W. Cty. Rd. B2
Roseville, MN 55113
P: 763-581-9250
F: 763-581-9251
Mon-Fri, 8:00 am - 8:00 pm
Sat–Sun, 9:00 am - 5:00 pm
Mobile On-Site
P: 763-581-9266
F: 763-581-0904
Call for information and scheduling
1/31/14 Brev

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