Forms & Questionnaires

For Business Owners

If your company partners with OMC for occupational health services, please use the following forms:

• Corporate Care Agreement (PDF)
• Secure Fax Agreement for Occupational Health Services (PDF)
• Company Profile—Protocol (PDF)

For Patients

Save time at your appointment by completing these forms before your visit:

General Forms

• Patient Record Release & Health History Forms (PDF)
• Authorization for Occupational Health Services (PDF)
• Authorization for After-Hours Occupational Health Services (PDF)
• Exposed Patient Consent for Testing for Occupational Exposure to Blood or Body Fluids (PDF)
• Medical Examination Report for Commercial Driver Medical Certification (DOT Form) (PDF)
• Occupational and Health History (PDF)

Patient Questionnaires

If your appointment requires specific screenings, please complete one of the following questionnaires:

• Respiratory Questionnaire for Occupational Health (PDF)
• Respiratory–Asbestos Questionnaire for Occupational Health (PDF)
• Tuberculosis Screening Questionnaire (PDF)

How to Submit Your Forms

You can:

• Fax completed forms to 507.292.7001
• Bring forms to your appointment
• Mail to:
  Olmsted Medical Center
  Attn: Occupational Health Services
  210 Ninth Street SE
  Rochester, MN 55904

Contact Us

Occupational Health Services
132 17 Avenue NW, Rochester, MN 55901
Monday–Friday, 7:00 AM–5:00 PM (closed holidays)
Phone: 507.292.7144
Fax: 507.292.7001