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Home > News & Updates > ... Customer Service > Occupational Health Account Set Up Form
News & Updates
Occupational Health Account Set Up Form
Occupational Health Account Set Up Form


It's very simple! Just complete this form to create an account with MEDSource One for any occupational health services. If you need to contact us for pricing information, please email Anne White at awhite@medsource-one.com. Once you have completed this form, we will contact you to insure all information is correct and to make any clarifications that are needed.


Company Name: *
Main Contact Name (First, Last): *
Second Contact Name (First, Last):
Physical Address (Street, City, State, Zip): *
Mailing Address (Street, City, State, Zip): *
Phone Number: *
Fax Number: *
Services Requested:
Workers' compensation treatment
Pre-employment physical
Annual physicals
OSHA Medical surveillance physicals
DOT Physicals
Drug/alcohol testing
Independent Medical Evaluations
Medical Respirator Clearances
Workers' compensation MCO (if state funded):
Workers' compensation TPA (if self-insured):
Post-accident drug/alcohol testing required?
5 panel urine drug screen
9 panel urine drug screen
Breath alcohol test
Check those that apply for exam requested:
 History & physical
Snellen vision screen
Titmus vision screen
Urinalysis, dipstick
Spirometry
Audiogram
Back/Lift Assessment
Chest X-ray
EKG, resting
Blood chemistries
5 panel drug screen
9 panel drug screen
Breath alcohol test
Other requests for examination:
Additional Comments/Requests for Information:
Captcha: *
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