Employer Authorization Form
For appointments call 630.539.5270.
TTY for the hearing impaired 630.933.4833
Scheduling hours: Monday – Friday, 8:00 am – 4:30 pm
This form may be faxed to 630.894.8028, emailed to [email protected]
or may be submitted by employee at time of service.
EMPLOYER INFORMATION
Company Name__________________________________________________________________________________________
Company Address________________________________________________________________________________________
Designated Employer Representative________________________________________________________________________
Company Phone Number_______________________________________________________________________________________
EMPLOYEE INFORMATION
Employee Name ___________________________________________________________ Date of Birth ______
_________________
Job Title__________________________________________________________________________________________________
APPOINTMENT INFORMATION
Appointment Date ___________________________________________________ Appointment Time _______________________
Name of Authorizing Person________________________________________________________________________________
SERVICE REQUESTED
NOTE: PHOTO ID IS REQUIRED. EXAMINEE SHOULD BRING CORRECTIVE LENSES/HEARING AIDS IF TYPICALLY WORN.
INJURY
Date of Injury ___________
Time of Injury __________
Employed By Staffing
Agency?
m NO
m YES
Staffing Agency Name
________________________
________________________
PHYSICAL EXAMINATION
Reason
m Pre-Employment/
Baseline
m Annual/Renewal/
Periodic
Physical Type
m Non-DOT
m DOT
m School Bus
m Respirator
m Return to Work
m Fit for Duty
m Asbestos
m Other _______________
Physical Also Includes
m Pre-Work Screen
m Respirator Certification
DRUG AND ALCOHOL
Reason
m Pre-Employment
m Random
m Post-Accident/Incident
m Post-CDL MVA
m Reasonable Suspicion
m Return to Work
m Follow-Up
Drug Screen
Non-DOT
m 5-Panel m 10-Panel
m Rapid m Lab-Based
m 5-Panel Lab Based Hair
DOT
Testing Agency
m FMSCA m FAA m FRA
m FTA m PHMSA m USCG
Collection
m Non-DOT
m Hair
m DOT
Alcohol Breath Test
m Non-DOT m DOT
OTHER SERVICES
m Hearing
m Vision
m TB Test – 1 Step
m TB Test – 2 Step
m Chest X-ray
Labs
m TB Quantiferon Gold
m Hepatitis B Surface
Antibody
m Mumps, Titer
m Rubella, Titer
m Rubeola, Titer
m Varicella, Titer
m Other _______________
Immunizations
m Hepatitis B Injection #1
m Hepatitis B Injection #2
m Hepatitis B Injection #3
m Hepatitis A Injection #1
m Hepatitis A Injection #2
m MMR Injection #1
m MMR Injection #2
m Flu Injection
m TDap Injection
Location map on back >
CADENCE HEALTH > OCCUPATIONAL HEALTH
Cadence Occupational Health Locations
Geneva Road
15
7
Warrenville
North Aurora Road
e
nu
ve
6
Naperville
6
Naperville
10
Cadence Travel Medicine
636 Raymond Drive, Suite 204
For more information, call 630.315.1730
Mon. - Wed., Fri. 8:00 am – 4:30 pm
Thursday
10:30 am – 7:00 pm
Saturday 8:00 am – Noon (one per month)
1
Aurora
Cadence Occupational Health
2635 Church Road, Suite 105
Mon. – Thurs. 8:00 am – 5:00 pm
Friday
8:00 am – 4:00 pm
2
Bloomingdale
Cadence Occupational Health
245 South Gary Avenue, Suite 200
Mon. – Thurs. 7:30 am – 5:00 pm
Friday
7:30 am – 4:00 pm
7
Glen Ellyn
Cadence Occupational Health at
HealthTrack Sports Wellness
875 Roosevelt Road, Suite 200
Mon. – Thurs. 8:00 am – 5:00 pm
Friday
8:00 am – 4:00 pm
Aurora
Cadence Convenient Care
2635 Church Road, Suite 101
Mon. – Thurs. 5:00 pm – 8:30 pm
Friday
4:00 pm– 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
8
Bartlett
Cadence Convenient Care
820 Route 59
Mon. – Fri.
7:30 am – 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
Naperville
Cadence Occupational Health
636 Raymond Drive, Suite 102
Mon. – Thurs. 8:00 am – 5:00 pm
Friday
8:00 am – 4:00 pm
St. Charles
Road
For scheduling appointments
630.539.5270
.
d
ar
12
St. Charles
Cadence Occupational Health
2900 Foxfield Road, Suite 207
Mon. – Thurs. 8:00 am – 5:00 pm
Friday 8:00 am – 4:00 pm
After Hours Care
4
Ave.
3
11
For customer service or sales 630.539.5246
Glen Ellyn
56
5
Travel Medicine
3
355
88
53
TTY for the hearing impaired 630.933.4833
Lisle
34
Woodridge
ad
r Ro
Occupational Health Clinics
4
Rive
Aurora
14
d Dr.
Diehl Road
Raymon
88
Penn
38
Wheaton
Ferry Road
Bilter Rd.
Farnsworth Avenue
Winfield Road
Butterfield Road
nA
1
de
Batavia
Kirk Road
way
Fabyan Park
Work injury treatment,
on-call post-injury/
accident and reasonablesuspicion drug and
alcohol screenings after
normal business hours of
full-service occupational
health clinics
Og
10
elt Road
nia
sylva
St
E.
Roosev
Jewell Road
290
64
ch
as
hi
ng
to
n
Geneva
Winfield
an
St
.
59
W
F ox R iver
Randall Road
St. Charles
Glen Ellyn Road
North Avenue
64
Bloomingdale
2
Main St.
Foxfield Road
Scott Dr.
Schmale Road
Main Street
il Road
Bl
13
Full-service
occupational health,
employment physicals,
drug and alcohol
screening, work injury
treatment
Itasca
20
9
Naperville Road
8
Stearns Road
Travel Medicine
Hanover
Park
County Farm Road
Bartlett
Army Tra
5
Elgin-O’Hare Expwy.
Gary Avenue
Dunham Road
59
9
11
12
Bloomingdale
Cadence Convenient Care
235 South Gary Avenue
Mon. – Thurs. 5:00 pm – 8:30 pm
Friday
4:00 pm – 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
13
St. Charles
Cadence Convenient Care
2900 Foxfield Road, Suite 100
Mon. – Thurs. 5:00 pm – 8:30 pm
Friday
4:00 pm – 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
Geneva
Delnor Hospital
Emergency Department
300 Randall Road
Open daily 24 hours
14
Wheaton
Cadence Convenient Care
7 Blanchard Circle, Suite 102
Mon. – Fri.
7:30 am – 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
Glen Ellyn
Cadence Convenient Care
885 Roosevelt Road, Suite 101
Mon. – Thurs. 5:00 pm – 8:30 pm
Friday
4:00 pm – 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
15
Winfield
Central DuPage Hospital
Emergency Department
25 North Winfield Road
Open daily 24 hours
Naperville
Cadence Convenient Care
636 Raymond Drive, Suite 106
Mon. – Thurs. 5:00 pm – 8:30 pm
Friday
4:00 pm – 8:30 pm
Sat. and Sun. 8:00 am – 6:00 pm
15-622/1014/500 © 2014 Cadence Health. All rights reserved. #40669