DOT Physical Request Form

I certify that the information I have provided is true and correct to the best of my knowledge. I authorize my information and test results to be disclosed to my employer, to any entity requiring DOT‑mandated reporting, and to the site or provider performing my physical examination for the purpose of completing the requested service.*

I acknowledge that payments are non‑refundable after the physical has been completed or if I leave the clinic after checking in. Some clinics may also charge a fee for missed appointments. I further understand that payment is due at the time the appointment is scheduled.*

I acknowledge that I am responsible for ensuring my employer receives my medical card unless I am notified of a different requirement.*