Occupational Medicine Clearance Form

Patient Name: Viacheslav Novikov Visit Date: 09/10/2023

Date of Birth: 08/26/1994 Patient ID: 25315678

Occupation: Payer Name: ESCREEN - NEW YORK

CityMD Location: CMDNY_ Midwood CityMD Address: 1305 KINGS HWY | BROOKLYN,
NY 11229-1903

Clinical Evaluation

Viacheslav Novikov was seen at CityMD for an employment related physical on 09/10/2023. Please contact the CityMD
Occupational Medicine Team at 866-MY-CITYMD or occmed@citymd.net with any questions.

Vitals:

Ht: Not Performed - Wt: Not Performed - BP: Not Performed -

Patient refused Patient refused Patient refused

Physical Exam:

None recorded
Assessment and Plan:

1. Administrative reason for encounter

Z02.1: Encounter for pre-employment examination
A HEALTHY LIFESTYLE: CARE INSTRUCTIONS
DRUG SCREEN, URINE

Discussion
Patient Instructions
Thank you for visiting Summit Health CityMD. We may be calling you to review your lab results or schedule a follow up
appointment. The call will be through an automated system which asks you to press a key to speak with one of our
agents. Please be on the lookout for this call and listen to the message in its entirety.

You may also view your lab results using the My Summit Health app, available in the App Store and Google Play. First-
time app users will need to create an account; please note you’ll need to select a login and password for the app versus
just using your patient portal login. Your lab results will be posted to the My Summit Health app as soon as they’re
available.

If you have any questions regarding your visit, our Aftercare department can be reached at 855-624-8963. Our hours are
Monday – Friday from 8 am – 11 pm or Saturday/Sunday from 9a – 8p.

Physician Signature:Electronically Signed by: SERGEY STROCHKOV MD

Date: 09/10/2023

Patient Signature:______________________________________________________Date: _____________