Fast Care Service

We have upgraded our Service Request System to provide a better experience.

Please visit our NEW Service Request Portal here:

Fast Care Service Request
Please Select your Service(s) Requested*

Injury Response (First Aid)Wellness Check (Follow Up)Drug TestFit TestTraining/CertificationsNew Hire ScreeningCOVID-19 Test/WitnessAccounting RelatedOther
Initial Triage Service Request

Fill the form below to schedule an Emergency Medical Technician to visit your jobsite. We will get back to you with an ETA.
Call 911 for Life Threatening Injuries!

Lllame al 911 para lesiones que amaenazan la vida!
Scheduled Date/Time

MonthDayYear
DateHourMinutesAM/PM Option
Company / Empresa*
Jobsite Name (Reference) / Nombre del sitio de trabajo*
Jobsite Address/Direccion del sitio de trabajo*

Street Address / direccion

Street Address Line 2

City / CiudadState / Estado

Zip Code / Codigo postal
Submit by

SupervisorSite ContactCorporate ContactDispatcher
Supervisor Full Name / Nombre del supervisor*
Supervisor Phone Number / Numero de telefono del supervisor*

Area CodePhone Number
Supervisor E-mail Address / Correo electronico
Site Contact Name / Nombre de contacto del sitio*
Site Contact Number / Numbero de contacto del sitio*

Area CodePhone Number
Site Contact Email
example@example.com
Corporate Contact Name
Corporate Contact Number

Area CodePhone Number
Corporate Contact Email
example@example.com
EMPLOYEE INFORMATION

INFORMACION DEL EMPLEADO
Employee Full Name / Nombre de empleado*
MaleFemale
Employee Phone Number

Area CodePhone Number
Language / Idioma

Fluent English / Ingles fluidoLittle English / Poco inglesSpanish Only / Solo espanol
SERVICE REQUESTED

SERVICIO SOLICITADO
Date of Incident / Fecha del incidente*

MonthDayYear
Date
Type of Incident / Tipo de incidente*

Eye Injury / Herida de ojoLaceration / LaceracionPuncture / PuncionStrains/Sprains / Cepas/EsguincesContusion/Bruise / Contusion/moretonHeat Illness / Enfermedad por calorOther / Otro
List Other / Lista*
Post Injury Drug Test?*

YesNo
Type of Test

UrineBreatheSaliva
Picture of Injury (Optional)

Browse Files

Cancelof
Hit his/her head? / Se golpeo la cabeza?*

YesNo
Loss of Consciousness? / Perdida de consciencia?*

YesNo
Neck or Back Injury? / Lesiones en el cuello o la espalda?*

YesNo
If bleeding, is it controlled with pressure? / Si sangra, se controla con presion?*

YesNo
Describe in detail what happened / Describe en detalle lo que paso?*
Provide specific details / Proporcionar detalles especificos
Date Requested

MonthDayYear
Date
Preferred Time
How Many Tests Requested?
Select Test Kit

Company ProvidedFast Care Provided
Drug Test Requested (select all requested)

Breath AlcoholDOT Breath AlcoholDOT Urine CollectionNon-DOT Urine Collection5 Panel Immediate10 Panel Immediate12 Panel Immediate14 Panel Immediate
How many Breath Alcohol Test Required?
How many DOT Breath Alcohol Test Required?
How Many DOT Urine Collection Required?
How Many Non-DOT Urine Collection Required?
How many immediate Urine Test?
Fit Test Requested

Qualitative Fit Test OnlyQuantitative Fit Test OnlyQualitative Full Package Fit Test With Pulmonary Function TestQuantitative Full Package Fit Test With Pulmonary Function Test
How many Qualitative Tests?
How many Quantitative Tests?
Training/Certification Requested
Accounting Related Request
Other Request
Should be Empty:

Initial Triage Service Request

EMPLOYEE INFORMATION

SERVICE REQUESTED