Gulf Coast Authorization (NEW)

Authorization for Testing
Company Information
Company Name*
Authorized By:*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail
Employee Information
Employee Name*

First NameLast Name
Employee Date of Birth

MonthDayYear
Job Number
If Applicable
Reason For Visit*

Pre-EmploymentRandomAnnualPost IncidentReasonable SuspicionOther
Date of Testing*

MonthDayYear
Testing Facility*

Main Clinic - 15389 Airline Hwy, Baton RougeGonzales Safety Council - 1205 W. Edenborne Pkwy, GonzalesBaton Rouge Safety Council - 10099 N. Reiger Rd, Baton RougeAddis Safety Council - 7640 Highway 1, AddisReserve Clinic - 3919 W. Airline Hwy, ReserveWalker Safety Council - 29756 Walker South Rd, Walker

Covid Testing
Covid testing

Covid instant AntigenPCR Covid testQualitative AntibodyQuantitative AntibodyCovid Taste test
ONLY at 15389 Airline Highway, Baton Rouge

VISION AND AUDIO TESTING
Vision Testing

Visual Acuity
Audio Testing

Baseline AudiogramAnnual AudiogramThreshold Shift Comparison (Additional Charge)

LAB BLOOD WORK
Labs

CMCCMPBenzeneLead/ZZPExecutive Profile (CBC, CMP, Lipids)TB Skin testTB T-Spot Blood TestOther

Authorization for Testing