Forms

Setup Account
On-Site Service Request
Medical Authorization

Setup Account

Ready to partner with us?

Fill out the form below to request an account setup. Once we receive your information, we’ll send you our Client Onboarding form to get started.

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On-Site Service Request

For on-site service in Louisiana, please contact:

[email protected]

225.408.5902 ext. 1035

For on-site services in Texas, please contact:

[email protected]

225.408.5902 ext. 2726

Medical Authorization

Please select a Clinic Location:*
- Baton Rouge
- Port Allen
- Reserve (LaPlace)
- Chalmette (N.O. East)
- Lafayette/Broussard
- Cities Service Highway (Sulphur)
- Baytown (North Main)
- Port Arthur
- Portland
Baton Rouge, LA*
- Launch Form
- Download Form
15475 Airline Highway Baton Rouge, LA 70817 Fax: 225-778-7542
Baytown, TX (North Main)*
- Launch Form
- Download Form
4404 N Main St. Baytown, TX 77521 Fax: 281-628-7010
Port Arthur, TX*
- Launch Form
- Download Form
3820 Hwy 365 Ste 500 Port Arthur, TX 77642
Port Allen, LA*
- Launch Form
- Download Form
3515 LA Highway 1 S Port Allen, LA 70767 Fax: 225-749-3138
Laplace, LA (Reserve)*
- Launch Form
- Download Form
3584 West Airline Highway Reserve, LA 70084 Fax: 985-536-3919
Chalmette, LA (N.O. East)*
- Launch Form
- Download Form
303 W. Judge Perez Chalmette, LA 70043 Fax: 504-570-6353
Lafayette, LA (Broussard)*
- Launch Form
- Download Form
106 Heritage Parkway, Broussard, LA 70518 Fax: 337-237-8666
Sulphur, LA (Cities Service Hwy)*
- Launch Form
- Download Form
2492 S Cities Service Hwy Suite 1 Sulphur, LA 70665 Fax: (337) 905-1963
Portland, TX*
- Launch Form
- Download Form
1500 Wildcat Dr. Suite M Portland, Texas 78374
Click to Download Form
Click to Download Form
- Employee Name:*
- Social Security #:*
- Company:*
- Company Contact Name:*
- Purchase Order Number:*
- Job Number:*
- Injury Treatment:
- Job Title:
Reason:*
- Pre-Placement
- Annual
- Semi-Annual
- Recertification
- Post Accident
- Random
- Other
Please Specify:*
Physical Exam:
- DOT
- Non-DOT
- Hazmat
- Asbestos
- Operator
- OGUK (By appointment ONLY)
- Offshore
- Other
Please Specify:*
Physical Performance Test:
- Pre-Placement
- Other
Please Specify:*
Breath Alcohol:
- DOT
- Non-DOT
Observation/Witness Collection:
- Yes
- No
Drug Screen:
- 5 Panel (Quick)
- 10 Panel (Quick)
- 12 Panel (Quick)
- Prime Non-DOT
- Prime DOT
- Synthetic Marijuana
- Synthetic Opioid
- PHMSA
- USCG
- FMSCA
- Other
Please Specify:*
Hair Test:
- Prime Hair Test (5 panel)
- Other
Please Specify*
DISA:
- BAT Non-DOT
- BAT DOT
- FMSCA
- Urine DOT
- PHMSA
- Urine Non-DOT
- Hair Test
- USCG
- Oral Non-DOT
- DISA Policy/Account:
- Other Lab:
Respirator Fit Test:
- Quantitative (PortaCount)
- Qualitative (Odor Test)
- Mask #1:
- Mask #2:
- Mask #3:
Check all that apply
- Pulmonary Function Test
- Medical Record Evaluation
- Audiogram
- Titmus Vision Testing
- Return to Work Clearance
- Fit for Duty Clearance
- Safety Evaluation
- TB Skin Test (Employee must be able to return to the clinic within 2-3 days to have test read)
- Laboratory Tests
Add STS Comparison?
- Yes
- No
Laboratory Tests:*
Other Tests
Authorized Signature*
- Phone*
- Email*