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OCEANSIDE3156 Vista Way, Suite 100Oceanside CA 92056-3608
phone: 760.681.5222fax: 760.681.5151
VISTA 2365 S. Melrose DriveVista CA 92081-8788
phone: 760.571.5910fax: 760.597.0349
MISSION VALLEY7485 Mission Valley Rd., Suit 100Mission Valley CA 92108-4422
phone: 619.900.1330fax: 619.431.3653
NATIONAL CITY 1510 Sweetwater Road, Suite B National City CA 91950
phone: 619.552.2870fax: 619.768.2596
The difference is how we treat you.WorkPartnersOHS.com
Patient Name: Date: Please note that a valid photo ID is required for all services.
Employer: Telephone:
Authorized by: Signature:
AUTHORIZATION FOR SERVICES OR TREATMENT
WORK INJURY TREATMENT
Work Comp Carrier:
Claim Number:
Does this injury require a Drug Screen?
Does this injury require a Breath Alcohol Test?
m
m
Yes
Yes
m
m
No
No
NON-INJURY SERVICES
m Physical Exam
m DMV / DOT Physical
DRUG SCREEN
m DOT Drug Screen
m Non-DOT Drug Screen
BAT BREATH ALCOHOL TEST
m DOT BAT
m Non-DOT BAT
m Audiogram
m Livescan Fingerprinting
m TB Skin Test
m TB Blood Test: TSPOT
m Titer:
m Vaccine:
m Other:
SPECIAL INSTRUCTIONS:
Body Part Injured: Left Right
™
The diff erence is how we treat you.WorkPartnersOHS.com
OCEANSIDE3156 Vista Way, Suite 100Oceanside CA 92056-3608760.681.5222
NATIONAL CITY
Hours of Operation:Monday – Friday: 8 AM – 6 PM Saturday: 9 AM – 2 PM
San Diego Fwy
El Camino Real
San Diego Fwy
El Camino Real Oceanside Clinic
Vista Way
El Camino Real
S. Melrose Drive
Syca
more Aven
ue
Vista Clinic
El Camino Real
S. Melrose Drive
Syca
more Aven
ue
Friar’s Road
15
805
8Mission Valley Clinic
S. Melrose Drive
Friar’s Road
National City Clinic
15 805
MISSION VALLEY7485 Mission Valley Rd., Ste. 100San Diego CA 92108-4422 619.900.1330
Hours of Operation:Monday – Friday: 8 AM – 6 PM
VISTA2365 S. Melrose DriveVista CA 92081-8788760.571.5910
Hours of Operation:Monday – Friday: 8 AM – 6 PM
1510 Sweetwater Road, Suite B National City CA 91950619.552.2870
Hours of Operation:Monday – Friday: 7 AM – 7 PM Saturday: 8 AM – 3 PM
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