General Intake Form

  • EMPLOYMENT (if currently employed)

  • FOR MINORS: I, the parent/legal guardian fully understand this authorization and grant permission to Accelerated Occupational Health (or its affiliated Urgent Cares) to conduct the evaluation, treatment, physical examination, and/or testing of the above named minor.

  • Digital Signature
  • ***For Office Use***

    EMPLOYER AUTHORIZED TREATMENT FOR INTIAL INJURY/GENERAL SERVICES:  YES   NO   Initials:      


    NAME OF AUTHORIZING PERSON:
    CONTACT NUMBER: