UT Health Services (UTHS) is the medical provider for the Occupational Health and Safety Program for UTHealth Houston. UTHealth Houston has indicated that you are in a job which requires enrollment in the Occupational Health Program; completion of this form ensures your enrollment in the Program. Please complete the form as able in its entirety - the information requested allows UTHS to assess potential risks to your health and to provide appropriate care. Completion of the form is required prior to any scheduled appointment with UTHS if necessary. You will be asked to upload proof of any immunizations at the end of this form.