Forms

For our clients convenience we have available the most commonly used forms so that they can be completed prior to your employees coming to the clinic. This will allow for expedited service and minimize the time your employees are away from work.

Company Profile

Used to register a company with Comprehensive Care.

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By registering your company you receive:

  • Discounted Pricing
  • Reduced Wait Times
  • Expedited Reporting
  • Concise Billing
Authorization Form

This form is completed and is either given to your employee to bring in or faxed to (219) 977-2091. The form is used to acknowledge that Comprehensive Care has permission to treat / test your employee.

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Patient Information – Consent Form

All Individuals coming to Comprehensive Care for treatment and/or testing are required to complete this form. The form will gather the entire patient’s demographic information to enter into our EMR system. In addition, it provides the disclosure statement informing the patient that any pertinent information gathered during the visit will be shared with the employer.

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DOT Physical

The DOT Physical Form must be completed for all DOT Physicals. This includes both initial as well as re-certification.

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Standard Physical

The Standard Physical Form is very comprehensive and thus is used in a variety of ways. The form must be completed in full so that a clinician can provide a true assessment as to the condition of an individual.

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The Standard Physical Form can be used for:

  • Pre-Employment Physicals
  • Annual Physicals
  • Periodic Physicals
  • Return-to-Work Physicals
  • Ability-to-Work Physicals
  • Exit Physicals
Health Questionnaire

The Health Questionnaire is typically used in conjunction with an ergonomic assessment or a job demand analysis. The form must be completed in full so that a clinician can review and render a qualification decision.

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Audiometric Form

This is the basic history questionnaire that all individuals receiving an audio test must complete.

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Respirator Certification

The Respirator Certification is the OSHA mandated questionnaire that must be completed and reviewed by a clinician to determine if an employee has the ability to wear a respirator as well as what classification of respirator they are qualified to wear.

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Spirometry (Pulmonary Function Test) Study Questionnaire

This form is used if an individual is required to have a PFT but is not having a Standard or DOT Physical.

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