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Who would be receiving care?

Someone else

Your info

First name

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Phone

Name you go by

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Administrative

Inquiry reason

How did you learn about our exam services

Please tell us how you were referred to our services. If you were referred by an individual, please list their name so we may thank them and offer a discount on their next visit.

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Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

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Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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Reason for care

What type of exam service do you need?

DOT DOT [Non CDL/Medical Card] Non-DOT [No medical card] DOT Urine Drug Screen Random Urine Drug Screen Non-DOT Urine Drug Screen Rapid Screen Urine Drug Screen Observed DOT Urine Drug Screen Observed Non-DOT Urine Drug Screen Pre-Employment TB Skin Test 1-Step TB Skin Test 2-Step Assisted Living [Employee] Day Care [Employee] with TB skin test Day Care [Employee] No TB skin test School Bus Driver AHSAA Sports Physical [School] College Sports Physical College Entrance Exam Pulmonary Function/Spirometry Test Questionnaire -OSHA Respiratory Review Only Miscellaneous/Other

Do you have any of the following health conditions which requires a letter from your doctor?

Please review and have your paperwork ready when you arrive for your appointment

Heart Attack or Stent Heart Surgery [such as bypass or heart valve] Pacemaker Any prescribed pain control medications Any medications for ADD/ADHD Any other medications listed as a controlled substance Obstructive Sleep Apnea requiring a CPAP/BiPap Insulin Use [Requires FMCSA form 5870 completed]

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.