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Please select a Clinic Location:*
Baton Rouge, LA*
15475 Airline Highway Baton Rouge, LA 70817 Fax: 225-778-7542
Baytown, TX (North Main)*
4404 N Main St. Baytown, TX 77521 Fax: 281-628-7010
Port Arthur, TX*
3820 Hwy 365 Ste 500 Port Arthur, TX 77642
Port Allen, LA*
3515 LA Highway 1 S Port Allen, LA 70767 Fax: 225-749-3138
Laplace, LA (Reserve)*
3584 West Airline Highway Reserve, LA 70084 Fax: 985-536-3919
Chalmette, LA (N.O. East)*
303 W. Judge Perez Chalmette, LA 70043 Fax: 504-570-6353
Lafayette, LA (Broussard)*
106 Heritage Parkway, Broussard, LA 70518 Fax: 337-237-8666
Sulphur, LA (Cities Service Hwy)*
2492 S Cities Service Hwy Suite 1 Sulphur, LA 70665 Fax: (337) 905-1963
Portland, TX*
1500 Wildcat Dr. Suite M Portland, Texas 78374
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*Indicates a required field, enter N/A if not applicable

Employer Details

Employee Details

Visit Details & Requests

Visit Type

PRIME Breath Alcohol & Drug Screen Types:

PRIME Screening Reason for Visit
Breath Alcohol
Quick Screen (Urine)
Non-DOT (Urine)
DOT (Urine)
PRIME Hair Test (5 Panel)
Drug Screen Observation

Additional Services:

Additional Services Reason for Visit
Physical Exam:
Functional Exam
Audiogram
Vision
Pulmonary Function Test
Respirator Fit Test
Stress Test (Referred Out)
Laboratory Test
TB Skin Test
Employee must be able to return to clinic within 48-72 hours to have test read.
X-Ray
Other Test Requests

3rd-Party Screening:

TPA Reason for Visit
TPA Services
DISA Policy

Employer Authorization

This certifies that the above information is correct. I authorize the medical provider to provide medical treatment to the employee named above. I also understand that the services provided will be paid in full by the company listed above and authorized by my signature below.

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