New Company Information 
Date__________

Local Company Info.

Name of  Company: _____________________________________________________________________________________________

Local Address:__________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Local Contact Person:____________________________________________________________________________________________

Local Phone: _____________________________________________        Local Fax:_________________________________________

Corporate Company info. (if applicable)
Corporate Address:______________________________________________________________________________________________

_______________________________________________________________________________________________________________

Corporate Contact Person:________________________________________________________________________________________

Corporate Phone: ______________________________        Corporate Fax:____________________________________

Billing/ Insurance Information
Billing Address:_________________________________________________________________________________________________

Billing Contact/Telephone:________________________________________________________________________________________

Workers Comp Ins Carrier:______________________________________________________________________________________

Workers Comp Ins Address:______________________________________________________________________________________

_______________________________________________________________________________________________________________

Workers Comp Contact/Telephone:________________________________________________________________________________

Number of Employees:_________

Drug Screens / Collections (MRO services):  Dr. Williams _____        Your own MRO_____     
*If your own check one: patient will bring cofc forms ______or company will send extras to our office_____

Drug Screen/Physical Results Reported To:____________________________________________________________
Paperwork returned to (check one): Employee:_____ Company:_____ 
*If  paperwork is returned to company circle how you would like it to be received- fax, mail, or both)
*if conducting DOT physicals please specify if you would like DOT cards: returned to employee_____ or mailed to employer_____

                                                                                                Services Offered- please check all services you would like us to provide
Workers Compensation Information
Post Accident Screens:     ___ on all post accident     ___ by request
___  No Screen
___  E-Screen (conformation included)
___ Quick cup screen (conformation not included)
___  Breath Alcohol Test/EBT
___  Non-DOT drug screen
___  DOT drug screen Drug Screen & Physical Information
Drug Screens:              Physicals:                   Misc:
___  E-Screen                          ___ Physical                     ___  X-Rays
___  Quick cup screen            ___ DOT physical            ___ Vac. & Immunizations
___  DOT Drug Screen           ___  Vision Screen           ___  Blood Work    
___  Pre-employment              ___  Audiogram               ___  Breach Alcohol Test
___  Random                           ___  Spirometry               ___  On-Site Screens
___  D/S collection
PRESIDENT/OWNER____________________________________________________________________________________
If you have questions regarding physicals or drug screens contact Mary Adams, For workers comp contact Marianne Childers (843) 744-3500
Once complete fax to: (843) 744-3938 Attn: Website Referral