New Client Account Setup | Lake Charles Urgent Care

New Client Information Services Requested

Company Name *

Company Address *

Street Address *

Address Line 2

City *

State *

ZIP Code *

Contact Information *

Phone Number *

Fax Number *

Contact Person *

Email *

Send Reports Via *

Fax Email Mail Other

Specify Other *

Billing Information *

Street Address *

Address Line 2

City *

State *

ZIP Code *

Accounts Payable Contact *

Worker's Comp Information*

Worker's Comp Insurance Company *

Street Address *

Address Line 2

City *

State *

ZIP Code *

Insurance Phone*

Policy Number *

Services Requested

Physical Examination Type *

Breath Alcohol Test *

DOT

NON-DOT

Drug Screen *

DOT

NON-DOT

Quick Screen

Hair

Other

If Other:

Additional Test (Other)

Injury Treatment

Post-Accident Drug Screen *

DOT

NON-DOT

Quick Screen

Post-Accident Breath Alcohol Test *

DOT

NON-DOT

New Client Information Services Requested

Services Requested

Injury Treatment

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