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First Name

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Phone Number

Existing Patient Options

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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

Date of Incident

Do you want to receive the WC164 report after each Physician Visit?

Please fill out preferred method of report receival.

Fax Number

Do you need any post-accident Drug or Alcohol Testing?

Drug Test Type

Do you also need a Breath Alcohol Test?

Physical Exam Type

Please indicate what vaccine(s) you require.

Vision Test Type

Do you wish to send a notification to your employee?

Employer Information

Company Name

Employer Contact Name (optional)

Employer Phone Number (optional)

Employer Email Address (optional)

Appointment Location

Select a location

Notification Emails (optional)

Comma separated, maximum of 3

Lakewood

7456 W. 5th Avenue, Suite 100,
Lakewood, CO 80226

Mon	7:00am - 5:00pm
Tue	7:00am - 5:00pm
Wed	7:00am - 5:00pm
Thu	7:00am - 5:00pm
Fri	7:00am - 5:00pm
Sat	Closed
Sun	Closed

Denver

2490 W. 26th Ave., Building A, Suite 5,
Denver , CO 80211

Mon	7:00am - 5:00pm
Tue	7:00am - 5:00pm
Wed	7:00am - 5:00pm
Thu	7:00am - 5:00pm
Fri	7:00am - 5:00pm
Sat	Closed
Sun	Closed

Thornton

9351 Grant Street, Suite 600,
Thornton, CO 80229

Mon	7:00am - 5:00pm
Tue	7:00am - 5:00pm
Wed	7:00am - 5:00pm
Thu	7:00am - 5:00pm
Fri	7:00am - 5:00pm
Sat	Closed
Sun	Closed

Request an Appointment

Which one applies to you?

I am a:

We need to collect some of your information.

Existing Patient Options

Please indicate the nature of your appointment.

Please indicate the nature of your appointment.

Employer Information

Employee Information

Appointment/Service Type

New Injury, Illness, or Exposure

Date of Incident

Do you want to receive the WC164 report after each Physician Visit?

Please fill out preferred method of report receival.

Which side of the body is injured?

Injured Body Part(s)

Do you need any post-accident Drug or Alcohol Testing?

Please indicate the nature of your appointment.

Drug Test Type

Do you also need a Breath Alcohol Test?

Physical Exam Type

Please indicate what vaccine(s) you require.

Vision Test Type

Do you wish to send a notification to your employee?

Employer Information

Appointment Location

Notification Emails (optional)

Lakewood

Denver

Thornton