Account Setup Form

Occupational Medicine Account Setup Form

Thank you for visiting our website. If you would like to set up an occupational Medicine account with First Med Urgent Care, please complete the form below. (If you are completing this form for First Med to be a drug screen collection site only, please include in the box below labeled “Other” the lab your company utilizes.

Lastname
Firstname		Middle

Company Name
Address

City	State		Zip
Phone	Fax
Contact Name		Title
Email Address

Other names of people at your company that can authorize treatment:
1.
2.
3.

Are you a worker's comp subscriber? Yes No

If Yes, please give us your work comp carrier's name and address

Services I am interested in (click all that apply)
On-the-job injury treatment
Post injury drug screens
Employment/Placement drug screens
Basic Physicals
DOT drug screens (NIDA)
DOT physicals
Drug Screen Collection Only
Audiometry
Spirometry
Breath Alcohol
Respirator
Asbestos
EKG
Lab
Xray
Other - Please describe any other services you are interested in:

Would you like an Occupational Representative to call you? Yes No

Would you like a Tour of one of our locations? Yes No

Do you have any special instructions or comments?

Questions? Please contact Patti Rudd”OCC Med Nurse” at (405) 478-0633