Request for Service
Company:
Date:
08/11/2005 07:44 AM
Employee Name:
DOB:
SS#:
Medical treatment for occupational injury
Date of Injury:
Time of Injury:
AM or PM
AM
PM
Urine Drug Screen
Reason:
Please choose one:
Pre-placement
Random
For Cause
Return to Work
Post-accident
Type:
Please choose one:
NIDA
Non-NIDA
DOT
Non-DOT
Other:
Breath Alcohol Testing
Physical Examination Type:
Please choose one:
DOT
Non-DOT
Return to Work Evaluation
Fitness for Duty Exam
Other services requested:
Please call with report:
Phone #:
Fax #:
Bill to:
Please choose one
Company
Insurance Carrier
Patient
Billing Address:
Comments:
Employer Contact / Approval:
Phone Number: