Request Care Form

Request Care Form

Request Care Form

Lovebird Healthcare

Company Name*
Designated Employee Rep & Phone*
Secondary/Backup Employee Rep & Phone
Primary Billing Contact
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Testing
1. Drug Free Workplace
No. of Employees
Average Hires/Month
Policy in place
2. Drug Test Profile
Drug Test Profile

5 Panel10 PanelWant HelpOther
Do you want immediate test results?

YesNo
3. Random Program - Complete below if you implement random testing

Type a question

	Number Employees in Pool	Percent or QTY to pull -DRUG	Percent or QTY to pull - ALCOHOL	Frequency	Point of Contact
Service Quality
DFWP

Testing
DOT Employees
# DOT Employees
Average Hires/Month
Government Agency
Policy in Place
Do you want immediate test results?

YesNo
Random Program (pick one)

Self-managedConsortium
Should be Empty: