Authorization for Testing
Company Information
Company Name
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Authorized By:
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First Name
Last Name
Phone Number
*
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Area Code
Phone Number
E-mail
Employee Information
Employee Name
*
First Name
Last Name
Employee Social Security Number
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Employee Date of Birth
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Month
-
Day
Year
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Job Number
If Applicable
Reason For Visit
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Pre-Employment
Random
Annual
Post Incident
Reasonable Suspicion
Other
Date of Testing
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Month
-
Day
Year
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Testing Facility
*
Main Clinic - 15389 Airline Hwy, Baton Rouge
Gonzales Safety Council - 1205 W. Edenborne Pkwy, Gonzales
Baton Rouge Safety Council - 10099 N. Reiger Rd, Baton Rouge
Addis Safety Council - 7640 Highway 1, Addis
Reserve Clinic - 3919 W. Airline Hwy, Reserve
Walker Safety Council - 29756 Walker South Rd, Walker
PHYSICAL EXAMINATIONS
Physical Examination
DOT Physical
Non-DOT Physical
Quantitative Physical
Asbestos Physical
HAZMAT Physical
Return to Work Physical
Crystalline Silica Physical ( Includes PFT, B-Reader, Chest X-Ray, TB Skin Test, Physical With Written Opinion)
Fit For Duty Physical
Complete Diamine Physical
ASAP TESTING
ASAP DRUG
LACC
ASAPCC
ASAP ALCOHOL
LACC
ASAPCC
DISA TESTING
DISA Alcohol
Non-DOT Breath Alcohol Test
DOT Breath Alcohol Test
Non-DOT Saliva Alcohol Test
DISA Drug Screen
DOT Drug Screen Collection
DCCHA Urine Drug Screen
DCCEO Urine Drug Screen
DCCOF Oral Fluid Drug Screen
DCCHT Hair Test WITHOUT Randoms
DCCHT Hair Test WITH Randoms
NASAP Urine Drug Screen
Other
DRUG SCREENS (NON-DISA)
Non-DOT Collection with Results
Non-DOT Drug Screen with Results (Enter Panel Number Below)
Drug Screen Panel
Enter Panel Number
Non-DOT Collection Only
Non-DOT Drug Screen (Enter Requested TPA Below)
TPA
Enter Requested TPA
DOT Drug Screen (Receiving Results from Gulf Coast)
DOT - FMCSA
DOT - PHMSA
Other
DOT Collection without Testing (Chain of Custody Provided)
DOT - FMCSA
DOT - PHMSA
Other
Instacheck
5 Panel
10 Panel
12 Panel
Hair Testing
5 Panel Hair
9 Panel Hair
Other
Observed Specimen? (Charges May Apply)
Yes
No
ALCOHOL (NON-DISA)
Alcohol Testing Type
Non-DOT
DOT
Breath
Saliva
TPA
ASAP
Forward Edge
Other
AUDIO TESTING
Audio Testing
Baseline Audiogram
Annual Audiogram
Threshold Shift Comparison (Additional Charge)
RESPIRATORY TESTING
Respiratory Testing
Fit Test (Select Mask Below)
Respiratory Clearance
PFT (Pulmonary Function Test)
Fit Test Masks
North 7660 Full Face
North 7700 1/2 Face
3M 6000 1/2 Face Series
3M 6800 Full Face Series
3M 7800 Full Face Series
MSA Comfo Classic 1/2 Face
MSA Ultraview Full Face
Scott 66 1/2 Face
Scott Oramic Full Face
Scott AV 2000 Full Face
Other
Facial Hair Approved
Must be checked or patient will be made to shave.
LAB BLOOD WORK
Labs
CMC
CMP
Benzene
Lead/ZZP
Executive Profile (CBC, CMP, Lipids)
Other
X-RAYS
X-Rays
Chest 1 View
Chest 2 View
Lumbar 3 View
Lumbar 5 View
Other
INJURIES OR OTHER NEEDS
Please Specify
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