\\vmstorage\MKTShare\Forms\FinalForms\OCC TA Updated 7/2/2019

*Employee will be evaluated to determine if he/she can perform the functions of the job. A written or verbal job description will be used at Physician’s discretion. ** Silica Exams Only - Services will take more than one day to complete and are only performed at selected locations ***Must bring mask & performed at selected locations only

Urgent Care | Occupational Medicine Open Everyday 8am –11pm | Select Locations Open 24 Hours

www.texasmedclinic.com

PHYSICALS Post Offer Physical*

Job Description On File Job Description Provided

DOT Physical

Respirator Physical

Hazardous Waste Physical

Asbestos Physical Initial Periodic Silica Dust Exams** (Includes: TB test, Chest X-Ray, Spirometry & Physical)

ANCILLARY TB test

X-ray authorized for TB Test if needed (Physician Evaluation Required)

T-Spot Blood Test

Audiogram

Spirometry

Respirator Fit Test***

Functional Ability Test (If authorized on company profile)

Vision Test

COMMENTS/ADDITIONAL SERVICES:

DRUG/ALCOHOL TESTING

Reason for Testing

Pre-Employment

Post Accident

Random

Reasonable Suspicion

For Cause

Follow -Up (DOT Only)

Return to Duty (DOT Only)

Other: _______________

Occupational Treatment Authorization

Company Name: ______________________________________________________ Employer ID # _________________ Address: ____________________________________________________________Store # ________________________ Phone: ____________________________________ After Hours Phone: ______________________________________ Person Authorizing (Please Print): ________________________________________________ Title: ________________ Authorization Expires on Date:_______________________________ Time:___________________________________

Employee Name: ________________________________________________________________________________

Job Title: ____________________________ Social Security #: ______________________ DOB:_________________

Electronic (Form Fox)

Employee will hand carry

Forms on file at clinic

Chain of Custody Form

RAPID DRUG TESTING

5 Panel

10 Panel

Non-DOT - Texas MedClinic lab only. Same day

negative results before 2 pm. Specimens requiring

further testing can take 2-7 business days depending

on results and date/time of collection.

BREATH ALCOHOL TESTING

Non-DOT

DOT

NON-DOT DRUG TESTING

5 Panel

10 Panel

Hair Drug Test

DOT DRUG TESTING

DOT Drug Test

FMCSA

FAA

FRA

FTA

PHMSA

USCG

DOT Testing Agency DOT Testing Authority

DOT

HHS

NRC

DISA

CMI

HireRight

Consortium/Third Party Administrator

Onsite Services

FleetScreen

Other: _____________

MMR

Varicella

Flu Shot

Other: __________

IMMUNIZATIONS

Hepatitis A

Hepatitis B

Varicella

MMR

Other: ____________

TITERS

Hepatitis A

Hepatitis B

Td

Tdap

*OCCTA*

Updated 7/29/2019

WURZBACH IH10 W/ Wurzbach (24 Hour) 9885 IH-10 West San Antonio, TX 78230 Ph: (210) 696.5599 Fx: (210) 699.8152 Clinic Manager: Jessica Elizondo Clinic Medical Director: James Bugg, MD occmed.wz@texasmedclinic.com

CULEBRA Loop 1604 / Culebra (24 Hour) 6530 W Loop 1604 N San Antonio, TX 78254 Ph: (210) 476.5577 Fx: (210) 688.9334 Clinic Manager: Ann Bartolett-Gonzalez Clinic Medical Director: John Cantu, MD occmed.cu@texasmedclinic.com

FORUM IH 35 N / Loop 1604 (24 Hour) 8341 Agora Pkwy San Antonio, TX 78154 Ph: (210) 659.5533 Fx: (210) 659.7755 Clinic Manager: Dan Sookchan Clinic Medical Director: James Murray, MD occmed.fm@texasmedclinic.com

LEON SPRINGS IH 10 W / Leon Springs 23611 IH 10 West • San Antonio, TX 78257 Ph: (210) 698.6617 | Fx: (210) 698.6627 Clinic Manager: Eddie Thomas Clinic Medical Director: Clayton Pullin, MD occmed.ls@texasmedclinic.com

EISENHAUER IH 35 N / Eisenhauer 7460 IH 35 North • San Antonio, TX 78218 Ph: (210) 655.5529 | Fx: (210) 655.5504 Clinic Manager: Jenny Lopez Clinic Medical Director: Angela Scalzi, MD occmed.es@texasmedclinic.com

BLANCO Blanco / Parliament 11811 Blanco Road • San Antonio, TX 78216 Ph: (210) 341.5588 | Fx: (210) 341.7513 Clinic Manager: Ernest DeLao Clinic Medical Director: James Bugg, MD occmed.bl@texasmedclinic.com

BROADWAY Loop 410 / Broadway 1007 NE Loop 410 • San Antonio, TX 78209 Ph: (210) 821.5598 | Fx: (210) 829.0125 Clinic Manager: Jenny Lopez Clinic Medical Director: James Murray, MD occmed.br@texasmedclinic.com

SOUTHEAST SE Military / Roosevelt 1111 SE Military • San Antonio, TX 78214 Ph: (210) 927.5580 | Fx: (210) 927.2700 Clinic Manager: Diana Barajas Clinic Medical Director: Brian Raimondo, MD occmed.se@texasmedclinic.com

BANDERA Loop 1604 / Bandera 9207 N Loop 1604 West • San Antonio, TX 78249 Ph: (210) 695.4884 | Fx: (210) 695.4949 Clinic Manager: Eddie Thomas Clinic Medical Director: Jeffery Weaver, MD occmed.bn@texasmedclinic.com

INGRAM Ingram/Loop 410 6570 Ingram Road • San Antonio, TX 78238 Ph: (210) 520.5588 | Fx: (210) 522.1125 Clinic Manager: Ernest Delao Clinic Medical Director: Paula Lyons, MD occmed.ig@texasmedclinic.com

STOTZER Hwy 151 / Loop 410 8519 State Hwy 151 • San Antonio, TX 78245 Ph: (210) 682.5577 | Fx: (210) 647.5566 Clinic Manager: Ann Bartolett-Gonzalez Clinic Medical Director: Joseph Elizondo, MD occmed.sz@texasmedclinic.com

STONE OAK 1604 / Stone Oak Pkwy 323 N 1604 West • San Antonio, TX 78232 Ph: (210) 549.5893 | Fx: (210) 549.5894 Clinic Manager: Shannon Fletcher Clinic Medical Director: Paula Lyons, MD occmed.so@texasmedclinic.com

Locations | San Antonio/New Braunfels

SOUTHWEST SW Military / Zarzamora 2530 SW Military Drive • San Antonio, TX 78224 Ph: (210) 476.5599 | Fx: (210) 455.9217 Clinic Manager: Diana Barajas Clinic Medical Dir: Brian Raimondo, MD occmed.sw@texasmedclinic.com

NEW BRAUNFELS IH 35 N / Hwy 46 958 IH 35 North • New Braunfels, TX 78130 Ph: (830) 606.5533 | Fx: (830) 606.5535 Clinic Manager: Destiny Cortez Clinic Medical Director: Ami Beshay, MD occmed.nb@texasmedclinic.com

OAK RUN Hwy 46/Oak Run Pkwy 1922 S State Hwy 46 W • New Braunfels, TX 78132 Ph: (830) 632.5092 | Fx: (830) 632.5094 Clinic Manager: Destiny Cortez Clinic Medical Director: Laura Perez, MD occmed.or@texasmedclinic.com

Locations | Austin/Round Rock

SOUTHPARK MEADOWS IH 35 S / Slaughter Lane 9900 South IH-35 • Austin, TX 78748 Ph: (512) 291.5577 | Fx: (512) 291.5576 Clinic Manager: Julie Koenning Clinic Medical Director: Glenda Peters-Do, MD occmed.sp@texasmedclinic.com

ROUND ROCK IH 35 N / Bass Pro Drive 4851 N IH 35 • Round Rock, TX 78664 Ph: (512) 486.6140 | Fx: (512) 863.4285 Clinic Manager: Kelly Bilsky Clinic Medical Director: Kristen Kocurek, MD occmed.rr@texasmedclinic.com

PARMER N MoPac / Parmer 12319 N MoPac Expy • Austin, TX 78758 Ph: (512) 835.5577 | Fx: (512) 836.0166 Clinic Manager: Juanita Peka Clinic Medical Director: Kristen Kocurek, MD occmed.pr@texasmedclinic.com

SINGING HILLS Hwy 281/Hwy 46 426 Singing Oak • Spring Branch, TX 78070 Ph: (830) 632.5740 | Fx: (830) 632.5743 Clinic Manager: Shannon Fletcher Clinic Medical Director: Angela Scalzi, MD occmed.sh@texasmedclinic.com