EMPLOYEE/PATIENT CONSENT FOR EXAMINATION OR TREATMENT

I (Please input Name below) hereby authorize C Perry Marshall, MD, DRM Business Health, PLLC, their employees, agents or assigns (hereinafter referred to as "Providers") to make a report to my employer, business, institution or other party as listed above concerning the collection and/or results of drug screens, physicals, breath alcohol testing, audiometry, spirometry and any other test requested by my employer or requesting party for consideration of employment, continued employment, or work related injury or reason established by police or party requesting the testing. I hereby authorize the us of these test results for the limited purpose listed herein and I understand that the requesting party has an independent duty to protect the confidentiality of the information released to the employers by Providers. Therefore, I hereby release Providers from any liability for damages to me, my family, agents or assign resulting directly or indirectly from Providers release of this information to the requesting party. I further understand that I have the right to withdraw my consent to the release of information; however, withdrawal of my consent does not affect any information disclosed prior to the written notice of my request for withdrawal. The undersigned, by signing this document represents that he/she has read and understands the above information and hereby consents to voluntarily submitting to the requested tests and the release of any resultant from information available learned from the results of the test to the requesting party listed above.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

OFFICE USE ONLY

DRUG AND ALCOHOL TESTING

PHYSICAL

POST OFFER OF EMPLOYMENT & FIT FOR DUTY

X-RAYS

OTHER SERVICES