EMPLOYMENT PHYSICALS AND SCREENING

DOT Physical

Post-Offer Physical (Non-DOT)

Return to Work

Merchant Marine / USCG

Law Enforcement/Fire Fighter

Flight physical (FAA)

Comprehensive/HazMat

Respiratory Certification Exam

Audiology

Vision

EKG

Other _______________________

_______________________________

IMMUNIZATIONS

Type(s): _________________________________________________________

OCCUPATIONAL INJURY AND ILLNESS CARE

Serious injuries call 911 or go directly to the Emergency Room. After hours injury care is available at MultiCare Urgent Care Centers and Emergency

Rooms. Urgent Care Centers and Emergency Rooms do not perform drug testing. Call the on-call collector (below)

New injury - Walk-ins welcome Follow-up injury care - Call for appt.

CHECK ALL SERVICES REQUIRED

Date

Employee/Patient Name

Job Position

Remarks & Requirements

Company Contact Signature Date

Employer contact complete or

staple business card here

Company Name

Address

City, ST, Zip

Contact Name

Contact Telephone

Contact Fax

Contact email

AUTHORIZATION - REFERRAL multicareoccmed.org

Serious injuries call 911 or go directly to the Emergency Room

After hours injury care is available at MultiCare Urgent Care Centers & Emergency Rooms. For Urgent Care locations visit www.multicare.org/urgent-care/

MultiCare Allenmore Medical Center Emergency Dept. 1901 S. Union Ave, Tacoma, WA 98405

MultiCare Auburn Medical Center Emergency Dept. 202 No. Division St. Auburn, WA 98001

MultiCare Covington Emergency Dept. 17700 SE 272nd St., Covington, WA 98042

MultiCare Good Samaritan Hospital Emergency Dept. 401 5th Ave SE, Puyallup, WA 98372

MultiCare Tacoma General Hospital Emergency Dept 315 Martin Luther King Jr Way, Tacoma, WA 98405 Rev.04/15

MultiCare Occupational Medicine - Kent 222 State Ave N Kent, WA 98030 p 253.545.5970

in the main MultiCare Kent Clinic

MultiCare Occupational Medicine - Fife 502 54th Ave E Fife, WA 98424 p 253.459.7569

Corner of 54th Ave E and 4th St E

MultiCare Occupational Medicine - Auburn 202 Cross St SE

Auburn, WA 98002 p 253.876.8140

at MultiCare Auburn Health Center

MultiCare Occupational Medicine - Tacoma 3124 S. 19th St #110 Tacoma, WA 98405

p 253.459.6658 1st Floor, Building C at Allenmore Medical Center

MultiCare Occupational Medicine - Puyallup 1450 5th St SE #1500 Puyallup, WA 98372

p 253.697.4014 1st Floor, Good Samaritan Medical Office Building

MultiCare Occupational Medicine - Lakewood 5700 - 100th St. SW #510

Lakewood, WA 98499 p 253.459.6005

Near Lakewood Town Center in the Lakewood Pavilion

LOCATIONS HOURS: Mon-Fri 8am - 4:30pm

FOR APPOINTMENTS: 888.280.5513 OPT 1

Employee/Patient MUST provide photo ID for all services. Please do not bring children requiring supervision to the clinic.

DRUG & ALCOHOL TESTING Walk-ins welcome. No unaccompanied minors

DOT Urine Drug Test

Non-DOT Urine Drug Test

EBT/Breath Alcohol Test

Other: ______________________

_______________________________

Pre-employment

Random

Reasonable Suspicion / For Cause

Post-accident or Injury

Return to Duty

Follow-up

After-hours drug & alcohol testing is available in some areas for post-injury/accident and reasonable suspicion. Call 253.327.4420 to reach the on-call collector.

Please call ahead for walk-in visits as hours occasionally vary.