Occupational Medicine New Client Account Form
Employer Information
Company Name:
Type of Business:
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
# of Employees:
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Contact and Result Reporting
Primary Contact:
First Name
Last Name
Title:
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Email:
*
example@example.com
Primary Contact Injury Work Status
Fax
Email
Primary Contact Employer Services Result Report
Fax
Email
Additional Contact:
First Name
Last Name
Title:
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Email:
*
example@example.com
Additional Contact Injury Work Status Report
Fax
Email
Additional Contact Employer Services Result Report
Fax
Email
Post-Accident Testing
Post-Accident Testing
Always
Not Required
Only when requested
Workers' Compensation Insurance Information
Workers Compensation Insurance:
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Authorized by:
*
First Name
Last Name
Title:
*
Phone:
*
Format: (000) 000-0000.
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
IRVINE LOCATION
15775 Laguna Canyon Rd., Suite 100
Irvine, CA 92618
P: (949) 417-0272 F: (949) 417-0276
www.sandcanyonurgentcare.com
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