Request Service Company Name *Person Requesting Service *FirstLastPhone *Email *EmailConfirm EmailDate / Time of Requested Service *Type of Service Being Requested *Select OneMobile On-Site ServicesNetwork Clinic ServicesContact Name (On-Site or Employee)FirstLastContact Phone (if applicable)Address of Employee or On-Site Location *REASON for Screening *Please Select a ReasonPre-EmploymentRandomPost-AccidentFor CauseSweepOther -If reason is other please enter reason below or if more than one reason please enter as well.Other - (explanation)Screening Service(s) Requested *DOT Drug ScreeningNon-DOT Drug ScreeningDOT Breath Alcohol ScreeningNon-DOT Breath Alcohol ScreeningHair Drug ScreeningOral Fluid Drug ScreeningOnsite Quick Test Screening Narcotic Detector Canine ServiceContraband Inspection ServiceDOT ModalityMake Selection only for DOT TestingUSCGFMCSAPHMSAFAAFRAFTAOccupational Medicine RequestedPre-Placement PhysicalDOT PhysicalRespirator Fit TestPulmonary Function Test (PFT)AudiogramReturn-to-Duty PhysicalNumber of Personnel to be Screened *Additional Notes or InstructionIf requesting Occupational Medicine services for employee(s) please include the following here: Employee Name, Date of Birth, Last 4 of SSN, Cell NumberSubmit
