Forms For Your Visit

Downloadable forms for patients and employers

Urgent Care - Patient forms

DOT CDL Forms

Employer forms

  • Patient Information Form (English & Spanish) — Every patient must complete and sign this form for his/her visit. The completed form is permanently filed in the patient’s chart. This form may be printed and completed in advance, or a copy will be made available when the patient/employee arrives at a Concentra location.
  • Injury Information Form — This form gives your doctor more information about your injury. If you’ve been injured, please complete this form in addition to the patient information form and bring it to your visit.
  • Employer Authorization Form — We must have a completed and signed Employer Authorization Form for any patient coming to a Concentra Medical Center for treatment of a first-time or new injury.
  • Employer Authorization and Information for Respiratory Evaluation — Employers authorizing respiratory physicals for their workers should download and complete the top portion of this form. The Clinician will complete the bottom portion which constitutes the written opinion regarding respirator use.
  • Request for Medical Surveillance Services — Employers interested in Medical Surveillance Exams from Concentra can complete this form in preparation for a discussion with one of our experts.
  • Regulatory Exam Authorization Form — Employers authorizing regulatory exams such as Respirator Clearance and Medical Surveillance should complete the attached and send it in with the employee.

Other forms