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Which one applies to you?
Employee
Employer
I am a:
New Patient
Existing Patient
We need to collect some of your information.
First Name
Last Name
Email Address (optional)
Phone Number
Existing Patient Options
Reschedule existing appointment
Schedule new appointment
Please indicate the nature of your appointment.
Physician Evaluation
Physical Therapy
Massage Therapy
Chiropratic
Please indicate the nature of your appointment.
DOT Physical
DOT Drug Screen
Other
Employer Information
Employer Representative First Name
Employer Representative Last Name
Company Name
Employer Representative Phone Number
Employer Representative Email Address
Employee Information
First Name
Last Name
Email Address (optional)
Phone Number
Appointment/Service Type
New Injury, Illness, or Exposure
Non Injury / Employee Health
New Injury, Illness, or Exposure
New Injury
Workplace Illness
Blood Borne Pathogen / Needlestick Exposure
Date of Incident
Do you want to receive the WC164 report after each Physician Visit?
Yes
No
Please fill out preferred method of report receival.
Email
Fax Number
Which side of the body is injured?
Right
Left
Both
Injured Body Part(s)
Head
Face
Neck
Chest
Back
Arm
Wrist
Hand
Finger
Hip
Leg
Knee
Ankle
Foot
Toe
Do you need any post-accident Drug or Alcohol Testing?
Yes
No
Please indicate the nature of your appointment.
Drug or Alcohol Test
Physical Exam
Physical Abilities Test
Range of Motion Test
Pulmonary Function Test
Respirator Fit Test
Hearing Test
Vision Test
Tuberculosis
Vaccination/Immunization
Immunization Titer Test
Other
Other Option
Drug Test Type
DOT Drug Screen
UDS Collection Only
4 Panel Rapid Drug Screen
5 Panel Rapid Drug Screen
9 Panel Rapid Drug Screen
10 Panel Rapid Drug Screen
Breath Alcohol Test (BAT)
Other
Other Test Type
Do you also need a Breath Alcohol Test?
Yes
No
Physical Exam Type
Department of Transportation (DOT)
PreEmployment
Return-to-Duty/Fitness-for-Duty
OSHA Respirator Clearance
OSHA Silica
OSHA Asbestos
OSHA Hazmat
OSHA Hazpower
Please indicate what vaccine(s) you require.
Hepatitus B (Series of 3 Injections)
Tetanus, Diptheria and Pertussis
Vision Test Type
Occupational Health Titmus Exam
Snellen Test
Jaeger Test
Ishihara Test
Do you wish to send a notification to your employee?
Yes
No
Appointment Location
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Denver
Thornton
Parker
Select a location
Notification Emails (optional)
Comma separated, maximum of 3
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