Client Account Request | Oregon Occupational Medicine

Injury Care
(acute injuries seen same day, provider will call you with employee’s work status)
Post accident drug screen on initial visit?
- Yes
- No
Breath Alcohol Test?
- Yes
- No
Additional Notes:

Alcohol Testing
(No appointment needed, please send a service authorization form with your employee)
Type of Testing:
- DOT
- Non-DOT
Reasons for Testing:
- Pre-employment
- Post-Accident
- Reasonable Cause
- Random
Bill DS Collection to:
- Company as listed above
- TPA
- Other:
Other

Reports and Contact
How would you like your reports sent?
***Unless otherwise noted, all results will only be sent to the primary contact listed above.***
- Fax
- Mail
- Email, indicate password below
Secure Fax #
Desired PDF Password
Reports via secure email are sent as a password-protected PDF, write your preferred 4-8 character password
Signature
Full Name
Signature*
My signature below indicates that I have authority to request these services for the above named company. I understand my company's requested services may be updated at my (or a named contact's) verbal or written request. I agree to the standard fee rates charged by Oregon Occupational Medicine, unless another financial agreement has been made. I understand that all accounts are net 30 and agree that payment will be made on these terms.
Title
Phone
Name
This field is for validation purposes and should be left unchanged.

Company Demographics