Please complete this form for the UC + TH location where services are to be provided. To inquire about appointment availability or to change or cancel an appointment, please call the Clinic you are scheduled at, and ask for the OHSS service representative or a clinic staff member. Napa (707) 377-1007, Sonoma (707) 940-1001, Petaluma (707) 940-5005, Benicia (707) 377-1005.

Employee should arrive at least 30 minutes early for their exam, and must bring the following:

• Government-issued ID (i.e., Driver’s License, Real ID, passport)
• All immunization records, if applicable and available
• TB Test records, if applicable and available
• Hearing aid (if applicable)

Services Requested

Preplacement Services:

**ATTENTION: Unless previously submitted, a job description is required at the time of the exam to avoid a delay in medical clearance.**

Non-Pre Placement Services:

Other services may be provided and billed at the physician/clinician’s discretion to give clearance on an applicant/employee as identified in your Letter of Agreement (LOA) under the “As Clinically Indicated” section of that visit category. If other screening/testing is needed and is not outlined in the LOA, we will call for authorization.

ADVISE EMPLOYEE TO CALL CLINIC DIRECTLY OR SCHEDULE ONLINE FOR APPOINTMENT.