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Northwest Medical Group

Patient & Employer Forms

Please send the completed forms to occmed@nwmedicalgroupwa.com

Patient Information Forms

Patient Information Form—Patients must complete and sign this form for their visit. It may be printed and completed in advance, or a copy will be given at the time of appointment check-in.

Release of Information: Please complete the following form to request patient records.

New Injury Intake Form - This form provides more information about your employee's injury. Please complete this and the patient information form and bring it to your visit.

DOT Physical Forms (CDL)

DOT Packet—This form contains the information DOT drivers can expect. It will be completed online at the clinic and does not need to be printed and completed beforehand.

Insulin-Treated Diabetes Mellitus Assessment Form—Commercial drivers with insulin-treated diabetes need to have this form completed by their treating clinician no more than 45 days before examination by a certified medical examiner. This form is required before a Medical Examiner's Certificate Form can be issued to a certified driver.

Employer Forms

Authorization for Services Form -This form must be returned to us at least one day in advance so that we can ensure we have the necessary supplies to provide services. This form authorizes us to perform other services, such as pre-employment physicals and drug screens.

OSHA Respirator Questionnaire -This form must be returned to us at least one day in advance so that we can ensure we have the necessary supplies to provide services. This form authorizes us to perform OSHA Respirator Fit Testing & Renewal.

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