3692 East Sam Houston Pkwy. South Suite 100 Pasadena, Texas 77505 281.998.2323 Please note that this Form will be reviewed by one of the OMC staff and is not to be considered an appointment. You will be contacted as soon as possible in order to set up an appointment. Regards, Occupational Medical Care.  DATE  NAME  EMAIL  Phone  Fax  SSN  DOB  Company  Job Site  Authorized By  Comments Please Check Appropriately Below  PHYSICALS  DRUG/ALCOHOL  Pre-Placement DOT Pre-Placement   Pre-Placement Post Accident   Periodic DOT   Re certification EBT   Return To Work Random   Asbestos For Cause   Benzene Non-Dot   VIP Urine / Alcohol  Saliva Breath Scan  Blood / Alcohol   LABORATORY  SCREENING  CBC w/Relic Audiometry   Lead ZZP EKG   Executive Profile Fit Testing  Spirometry  X-Rays  Back  # of Back Views  Chest  # of Chest Views   INJURY