Medical Evaluation Appointment Form This form is to be completed by a TriMedical physician. Employer / Company Name & Job Title Name * First Name Last Name Date of Birth Phone Number: * Based on the information provided, we recommend that the employee be placed in the following classification: Health status compatible with job requirements Health status compatible with job requirements requiring preventive restrictions Status pending further evaluation Status pending supplementary documentation Health status not compatible with the occupational requirements of the job and may expose the applicant/candidate/employee or others to other health and safety risks Physician's Comments Thank you for submitting an injury assessment evaluation form. A member of your intake team will review your request and get in touch regarding an appointment.
