21081 S. Western Ave. Suite 150, Torrance, CA 90501

Western Medical Group

Demographics/Physical/Drug Test

  • WESTERN MEDICAL GROUP

    21081 S. Western Avenue, #150 Tortance, CA 90501
    (310) 782-333 / Fax: (310) 212 - 6230
  • Demographics For Physical & Drug Screening

  • Patient's Name / Nombre Del Paciente :
  • Home Address / Direccion Del Paciente :
  • Employer's Adrress / Direccion De Su Empleo:
  • I consent freely and voluntarily for WESTERN MEDICAL GROUP to perform any of the following services that include but are not limited to; physical examination, x-rays, laboratory testing, or treatment. I hereby and herewith release WESTERN MEDICAL GROUP, their employees, agents and contractors from any liability whatsoever arising from this request. I understand that I have a right to receive a copy of this authorization upon request. I hereby authorize WESTERN MEDICAL GROUP to release all results or any information relating from this examination to:

    Yo doy mi consentimiento libre y voluntariamente para WESTERN MEDICAL GROUP desempen cualquiera de los servicios siguientes que incluyen el examen fisico, radiografias , y laborotorio. WESTERN MEDICAL GROUP y sus empleados, agentes, y los contratistas no tendran ninguna responsabilidad sobre estos resultados proviniendo desde este pedido. Yo comprendo que tengo derecho de recibir uno copia de esta authorization sobre el pedido.Yo authorizo a WESTERN MEDICAL GROUP a que de cualquiera de los resultados o cualquier information que relaciona sobre este examen: