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Click ‘Get Form’ to open the WellSpan Occupational Health form in the editor.
Begin by entering the employee's name and address in the designated fields. Ensure accuracy as this information is crucial for identification.
Indicate if the employee is associated with a staffing agency by selecting 'Yes' or 'No'. If 'Yes', provide the agency's name.
Fill in the authorized person's name, social security number, date of birth, and email address. This information is necessary for verification purposes.
Select all applicable reasons for the visit from the checklist provided. This may include options like work-related injury or physical examination.
If substance abuse testing is required, check the relevant boxes and specify any additional details needed for testing.
Review your entries for accuracy before saving or submitting the form. Utilize our platform’s features to make any necessary edits easily.

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