Forms

This page provides access to key forms that are required at Omega Medical Center. Forms may be downloaded from the right side bar. Please follow the instructions below for use of these forms.

Employer Authorization Form

  • We must have a completed and signed Employer Authorization Form for any new patient who comes to Omega Medical Center for treatment of a first-time or new injury. This authorization form — completed and signed — must be in our possession to begin treatment. There are two ways of getting this form to us:
    • The patient presents it to the receptionist on arrival.
    • The employer/supervisor faxes a completed and signed form to Omega to hold on file until the patient arrives for treatment.

Services Required

  • Employers should complete this form indicating which service(s) the employee requires. To get this form to us:
    • The patient presents it to the receptionist on arrival.
    • The employer/supervisor faxes a completed and signed form to Omega to hold on file until the patient arrives for treatment.

Patient Information Form

  • Every patient must complete and sign this form for his/her visit. The completed form is permanently filed in the patient’s chart.
    • Form is printed in English and Spanish.
    • May be printed and completed in advance or a copy will be made available when the patient arrives at Omega.

Traveler’s Questionnaire

This form should be completed by any patient who plans to travel outside the country and is in need of Travel Medicine Services.

Note: Photo Identification Required for Drug Screening. All patients undergoing drug screening must present valid photo identification before the procedure. Acceptable forms of identification include a driver’s license, work badge or passport.