Occupational Health New Client Form

Checkmark

Check In Online

No appointment needed

General Information
Contact Person
Alternate Contact Person
Mailing Address
Billing Address
How did you hear about Lansing Urgent Care's Occupational Medicine Program?
Workers Compensation Insurance Information
WC Insurance Billing Address
WC Contact Person & Phone
Would you like your WC Invoices billed to
Services Needed
Pre-Placement Physicals to Include
Drug Screening Information (if applicable)
Services Needed (check all that apply)
Do you Have a Third Party Administrator for Your Company's Drug Screening Program
Please answer the following questions to the best of your ability
Occupational Injury
Please check all testing you would like performed in the event of an occupational injury
Occupational Injury Services Needed
How would you like to receive employee results?
New Hire/Pre-Employment
Please check all testing you would like performed during new hire/pre-employment
New Hire/Pre-Employment
How would you like to receive employee results