EmailMeForm
Employer Request & Authorization
Please ensure your employee brings a valid photo ID
Choose clinic location
Please select
Aurora - S Buckley Rd
Brighton
Broomfield - Hwy 287
Broomfield - W 144th Ave
Centennial - Southglenn
Denver - Central Park
Fort Lupton
Lafayette
Northglenn
Thornton - E 136th Ave
Westminster - Federal Blvd
Westminster - Wadsworth Pkwy
General Information
Employee Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Preferred Language
English
Spanish
Other
Employer/Company Name
*
Third Party Administrator Name (TPA)
Vaccinations
Type of Vaccination
Tetanus
Physical Exam
Type of Physical
Non DOT
DOT
Return to Work (Fit for Duty)
Workers Compensation
New Work Injury
Other Services
Please specify any other services needed
File Upload
Upload any additional Protocols or Authorization forms as needed
Billing
Direct Bill to Employer
Employee to Pay Charges
Bill to Worker's Compensation Insurance
Claim Number
Employer Name
Authorization
HR/Billing Contact
HR/Billing Contact Number
HR/Billing Email
HR/Billing Signature
Clear
