Visual prototype. Nothing entered here is saved, signed, or transmitted.
DJ
De Jesus Platform Works Vision Examination Portal
LR
L. Ramirez · Company Administrator
Ramirez Aero Services

Employer authorization

Authorize the clinic site to perform an annual vision examination for one of your employees. The employee presents this form at the clinic site.

Employee
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Authorization terms
Authorized by
Authorizing signature
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Luis Ramirez · Ramirez Aero Services Not yet signed

Employer Authorization

Annual Vision Examination · AUTH-2026-00148
Draft
Valid through Sep 15, 2027
Employee
Joaquin Ferreira
Employee number
RAS-31877
Job function
Welder — non-NDT
Date of birth
November 02, 1979
Employer
Ramirez Aero Services
Clinic site
Demo Vision Clinic
Authorization

Ramirez Aero Services authorizes Demo Vision Clinic to perform an annual vision examination for the employee named above, and authorizes release of the resulting examination record to the authorized recipients of Ramirez Aero Services. This authorization does not direct or influence the examination result or the Level III determination.

Authorized by
Name
Luis Ramirez
Title
Quality Manager
Signed
Not yet signed
Billing reference
—
Present this form at the clinic site

The examiner scans this code to open the authorization. No personal or medical information is encoded — the code contains only the authorization number.

Sample authorization for prototype review only. Not a valid authorization. Software provided by De Jesus Platform Works, LLC.