Southern Immediate Care Occupational Medicine Employer Form

Southern Immediate Care Occupational Medicine Employer Form
Today’s Date*

MonthDayYear
Date
Employer*
Contact Name*
Employer Address*
Employer Address - City, State ZIP*
Billing Address (if different)
Billing Address - City, State ZIP
Employer Phone Number*
Employer Fax Number*
Services requested for today’s visit to SIC

Urine Drug Screen In-house 10 panel - $35Confirmation Send Out - $35TB Skin Test - $20Chest X-Ray - $50COVID Swab - $100DOT Exam - $100DOT Drug Screen (send out) - $50
*Drug Screens must arrive 3 hours before the clinic's closing time*

Monday – Friday: 8 am to 6 pm Saturday – Sunday 9 am – 1 pm

Please complete this form at your earliest convenience. Thank you for choosing us as a healthcare provider for your employees.
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