On-Site Service Request

On-Site Service Request

Louisiana Occupational Health Services
COMPANY INFORMATION
Company Name *
DBA
Contact Person*

First NameLast Name
Title
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Restricted Release Information
I authorize the below personnel, ONLY, to obtain employee medical information and/or drug screen results via email, fax, and/or verbal reports from Louisiana Occupational Health Services. I confirm the below personnel will maintain confidentiality with regards to any and all reports received. The company agrees to update this form in the event any authorized personnel changes are made. All medical information and drug screen results will be EMAILED to the following personnel.
Authorized Personnel to receive Employee Medical Information*

First NameLast Name
Email for results to be sent to.*
example@example.com
On-Site Service Request
Please Select Requested On-Site Services Below.*
LOHS can provide your business with quality Occupational Health screening at your job site for the convenience of your workforce. Whether onboarding new hires or conducting annual testing; our staff offers a variety of services, as well as flexible scheduling, to accommodate you and your employee's needs. On-Site Service fulfillment will be determined on quantity, location, and tech availability. There is an additional $150.00 charge for less than 10 employees. After submission, LOHS will contact you to confirm the On-Site request.
Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Louisiana Occupational Health Services - 3018 Jackson St., St.100, Alexandria, LA 71301

P:(318)561-8200 F:(318)561-8204 www.lohs.net
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On-Site Service Request

Restricted Release Information