MedFirst Medical Center
2731-B Capital Boulevard
Raleigh, NC 27604
Phone: 919-878-4647
Fax: 919-878-1541

Our goal is to provide you with the best possible service. If you have any suggestions or comments on how we can better serve you, please call Dr. Samia directly, because your suggestions help us be more effective and will also benefit fellow corporate partners.

Attention New Corporate Partner: Please contact Dr. Samia directly at 919-878-4647 to discuss setting up an account with MedFirst. After he determines how to best meet your needs, your company will be introduced to the MedFirst team.

Existing Corporate Partners: Please fill out the enclosed form below and click submit to forward to MedFirst.

 

Authorization For Treatment Form

Patient's Name *

Company Name

Authorizing Person

Phone *

Service(s) Requested
Work Related Injury
Drug Screen--5 Panel (DOT regulated)
"Quick" Drug Screen
Breath Alcohol Test
General Physical
Physical Abilities Testing
Teacher Physical
Pulmonary Function Test
Hepatitis B Vaccine
Travel Medicine Services


Return to Work Evaluation
Drug Screen--9 Panel (non-DOT regulated)
"eScreen" Drug Screen
DOT Physical
Annual Medical Surveillance Exam
Daycare Physical
TB Skin Test/PPD
Audiogram
Hepatitis B Titer/Blood Test
Flu Shot

Other Services or Instructions
Fax this completed authorization form to 919-878-1541.

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