Employee Health Diagnostic Evaluation Consent Form
Complete this form to provide the information needed for an employee health diagnostic evaluation and related consent.
Employee Information
Employee Full Name
*
First Name
Middle Name
Last Name
Employee ID
Job Title / Position
*
Department / Team
*
Work Location / Site
*
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
example@example.com
Evaluation Details
Evaluation Type / Reason
*
Please Select
Routine screening
Follow-up evaluation
Symptom-based evaluation
Return-to-work clearance
Other
Date Requested
*
-
Month
-
Day
Year
Date
Preferred Appointment Date/Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Notes About Why the Evaluation Is Needed
Health Information
Current symptoms or health concerns
*
Relevant medical history related to this evaluation
Current medications and supplements
Allergies or sensitivities
Recent illness, exposure, or injury in the past 14 days
*
No
Yes
Prefer not to say
Accommodations or special instructions for the evaluation
Emergency and Provider Information
Emergency Contact Name
*
Relationship to Emergency Contact
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Provider or Clinic Name
Preferred Communication Method for Follow-Up
*
Phone
Email
Either
Consent and Acknowledgment
Consent Statement
Consent and Acknowledgment
*
I agree and consent
I do not agree
Submit
Should be Empty: