MAKE AN APPOINTMENT

Authorization For Services

EMPLOYEE INSTRUCTIONS: Please bring this form with you when you come to HealthRoute. The office requires the information on this form in order to correctly process your test. Please note failure to present this form to the office at the time of service may delay the processing of your test.

Payment will be made by: Choose one
Type of Service Requested: Choose one
Please specify service needed: Choose one or more

Reason for test (circle one):
pre-employment, random, post accident, reasonable cause, follow up

Reason for test (circle one): pre-employment, random, post accident, reasonable cause, follow up

Reason for test (circle one):
pre-employment, random, post accident, reasonable cause, follow up

Reason for test (circle one): pre-employment, random, post accident, reasonable cause, follow up

Reason for test (circle one):
pre-employment, random, post accident, reasonable cause, follow up

HealthRoute

65 Wekiva Springs Rd Suite 231C Longwood,Fl 32779
Monday 1pm -5pm and Tuesday 1pm -5pm