OCCUPATIONAL MEDICINE: DEMOGRAPHICS AND 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the shaded area with your personal information, including your name, phone number, address, age, social security number, employer, and sex. Ensure all details are accurate for proper processing.
3. Provide your date of birth and emergency contact information. This is crucial for any urgent situations that may arise during your evaluation.
4. Read through the authorization sections carefully. These include consent for evaluation/treatment and release of medical forms. Make sure you understand what you are authorizing before signing.
5. Complete the functional skills assessment authorization section by acknowledging your understanding of the testing procedures and potential risks involved.
6. If applicable, fill out the patient x-ray consent section by confirming your understanding of the procedure and any associated risks.
7. Finally, acknowledge receipt of the privacy notice and provide any restrictions concerning your medical information before signing and dating the form.

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