EmailMeForm
Employer Request & Authorization (Old)
Please ensure your employee brings valid identification.
Choose clinic location
Please select
Brighton
Fort Lupton
Northglenn
General Information
Employee Name
*
First
Last
Gender
*
Please select
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Employer/Company Name
*
Temp/Staffing Agency Name
Clinical Services
Check the type of service(s) requested.
Drug and Alcohol Testing
DOT Urine Drug Testing
Non-DOT Urine Drug Testing
DOT Breath Alcohol Testing
Non-DOT Breath Alcohol Testing
Non-DOT Hair Collection Testing
Other, please explain:
Type of Drug and Alcohol Testing
Pre-Employment
Post-Accident
Reasonable Suspicion
Random
Return-to-Duty
Follow-Up
Other, please explain:
X-Ray
Chest
B Read (Silica Testing)
If other region, please specify:
Worker's Compensation
New Injury
Work Comp Medical History
Physical Examination
Non-DOT Pre-Employment
Non-DOT Physical
DOT Physical (New)
DOT Physical (Recertification)
Return to Work
Annual/Biannual
Respirator Fit Testing Type (check all that apply)
Quantitative (Fort Lupton Only)
Qualitative
Respirator Fit Mask Type (check all that apply)
Full Mask
Half Mask
Special Examination
OSHA Questionnaire Review
Pulmonary Function Test (Spirometry)
Audiogram
Vision Test
Physical Capability Exam (Lift Test)
Provider Risk Assessment
Other, please explain:
Vaccinations
Flu
Hep A
Hep B
Tetanus
PPD/Tuberculosis
Other services requested:
File Upload
Upload any additional Protocols or Authorization forms as needed
Employer Authorization
Billing
*
Bill to Worker's Compensation Insurance
Direct Bill to Employer
Employee to pay charges
Work Comp Claim Number
Company Representative Name
*
Company Representative Phone Number
*
Company Representative Email
*
Company Representative Signature
*
Clear