Medical Plaza. Providence Occupational Medicine-. Mill Plain is on the second
floor, Suite 200. Heading north on I-205, take the Mill Plain exit. Turn right on Mill
...
Providence Occupational Medicine-Mill Plain
315 SE Stone Mill Drive, Suite 200 Vancouver, WA 98684
Appointment scheduling: 503-216-7960
Clinic hours: 8 a.m. to 5 p.m., Monday-Friday
Clinic phone: 360-836-3326 Fax: 360-836-3325
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DIRECTIONS FROM I-205 SOUTH
DIRECTIONS FROM I-205 NORTH
Heading south on I-205, take the Mill Plain exit. Turn left on Mill Plain, then turn left at 136th Avenue. Take the second left onto Stone Mill Drive and turn into the parking lot for Providence Mill Plain Medical Plaza. Providence Occupational Medicine-Mill Plain is on the second floor, Suite 200.
Heading north on I-205, take the Mill Plain exit. Turn right on Mill Plain, then turn left at 136th Avenue. Take the second left onto Stone Mill Drive and turn into the parking lot for Providence Mill Plain Medical Plaza. Providence Occupational Medicine-Mill Plain is on the second floor, Suite 200.
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Providence Occupational Medicine ©2016
Providence Occupational Medicine-Mill Plain
315 SE Stone Mill Drive, Suite 200 Vancouver, WA 98684
Appointment scheduling: 503-216-7960
Clinic hours: 8 a.m. to 5 p.m., Monday-Friday
Clinic phone: 360-836-3326 Fax: 360-836-3325
Employee/applicant name:______________________________ Authorized by:_______________________________ Company name:________________________________________ Date/time left work:__________________________ Job title:_______________________________________________ Protocol name:_______________________________ Scheduled services/Reason for visit: (Please check all that apply.) Pre-placement exam Optional services (please specify)_______________________ DOT exam - New Optional services (please specify)_______________________ DOT exam - Recertification Optional services (please specify)_______________________ Bus driver exam - New Optional services (please specify)_______________________ Bus driver exam - Recertification Optional services (please specify)_______________________ Medical surveillance exam - Baseline Optional services (please specify)_______________________ Medical surveillance exam - Periodic Optional services (please specify)_______________________ Medical surveillance exam – Exit Optional services (please specify)_______________________ Firefighter exam Optional services (please specify)_______________________ Police officer exam (DPSST) Optional services (please specify)_______________________ Respirator exam Respirator fit test Other exam (please specify)___________________________________________________________________________ Walk-in services/Reason for visit: (Please check all that apply.) Substance testing: Pre-placement Random Post-injury Reasonable suspicion/For-cause Follow-up Other DOT (FMCSA) DOT (PHMSA) DOT (USCG) DOT (FTA) DOT (FAA) DOT (FRA) Non-DOT Express/Rapid Breath alcohol test: DOT Non-DOT Ancillary services: Audiogram: Baseline Annual TB skin test Immunization (please specify)_________________________________________________________________________ Antibody testing (please specify)______________________________________________________________________ Other (please specify)________________________________________________________________________________ Customer notice: 1. We work hard to accommodate everyone, and we respect your time. Walk-in services, such as drug screens, hearing tests and immunizations, are performed on a first-come, first-served basis. Occasionally, extended waits may occur; however, we make every effort to keep your wait to a minimum and will inform you of delays. 2. Your employer or Department of Transportation (DOT) regulations may require that you remain in our facility if you cannot provide an acceptable drug test specimen. Please allow adequate time in your schedule for the possibility of an extended visit due to retesting. 3. Please bring photo identification issued by local, state or federal government (e.g., your driver’s license).
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Providence Occupational Medicine ©2016
