Dept of Transportation (DOT) Form

We would like to inform you of the following information that applies to DOT physicals at this facility:

1 Please be aware that the $130 charge for the DOT physical is not refundable if you fail the physical.

2. Iffollow up visits are required in order for us to approve your DOT physical there are fees associated with those follow up visits; however, you can use your health insurance for the follow up visits, but not the initial visit.

3. If you are on ANY NARCOTIC MEDICATION this office will deny your physical and fees are NON-REFUNDABLE. Please inform the front desk staff of this before coming back for your physical.

By signing this form you are acknowledging and agreeing to these policies.

Do you have or have you ever had:

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35 and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.