Please Select your Service(s) Requested
*
Injury Response (First Aid)
Wellness Check (Follow Up)
Drug Test
Fit Test
Training/Certifications
New Hire Screening
COVID-19 Test/Witness
Accounting Related
Other
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
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Date
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Minutes
AM
PM
AM/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 / Ciudad
State / Estado
Zip Code / Codigo postal
Submit by
Supervisor
Site Contact
Corporate Contact
Dispatcher
Supervisor Full Name / Nombre del supervisor
*
Supervisor Phone Number / Numero de telefono del supervisor
*
-
Area Code
Phone Number
Supervisor E-mail Address / Correo electronico
Site Contact Name / Nombre de contacto del sitio
*
Site Contact Number / Numbero de contacto del sitio
*
-
Area Code
Phone Number
Site Contact Email
example@example.com
Corporate Contact Name
Corporate Contact Number
-
Area Code
Phone Number
Corporate Contact Email
example@example.com
EMPLOYEE INFORMATION
INFORMACION DEL EMPLEADO
Employee Full Name / Nombre de empleado
*
Male
Female
Employee Phone Number
-
Area Code
Phone Number
Language / Idioma
Fluent English / Ingles fluido
Little English / Poco ingles
Spanish Only / Solo espanol
SERVICE REQUESTED
SERVICIO SOLICITADO
Date of Incident / Fecha del incidente
*
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Month
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Day
Year
Date
Type of Incident / Tipo de incidente
*
Eye Injury / Herida de ojo
Laceration / Laceracion
Puncture / Puncion
Strains/Sprains / Cepas/Esguinces
Contusion/Bruise / Contusion/moreton
Heat Illness / Enfermedad por calor
Other / Otro
List Other / Lista
*
Post Injury Drug Test?
*
Yes
No
Type of Test
Urine
Breathe
Saliva
Picture of Injury (Optional)
Browse Files
Cancel
of
Hit his/her head? / Se golpeo la cabeza?
*
Yes
No
Loss of Consciousness? / Perdida de consciencia?
*
Yes
No
Neck or Back Injury? / Lesiones en el cuello o la espalda?
*
Yes
No
If bleeding, is it controlled with pressure? / Si sangra, se controla con presion?
*
Yes
No
Describe in detail what happened / Describe en detalle lo que paso?
*
Provide specific details / Proporcionar detalles especificos
Date Requested
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Month
-
Day
Year
Date
Preferred Time
How Many Tests Requested?
Select Test Kit
Company Provided
Fast Care Provided
Drug Test Requested (select all requested)
Breath Alcohol
DOT Breath Alcohol
DOT Urine Collection
Non-DOT Urine Collection
5 Panel Immediate
10 Panel Immediate
12 Panel Immediate
14 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 Only
Quantitative Fit Test Only
Qualitative Full Package Fit Test With Pulmonary Function Test
Quantitative Full Package Fit Test With Pulmonary Function Test
How many Qualitative Tests?
How many Quantitative Tests?
Training/Certification Requested
Accounting Related Request
Other Request
Submit / Enviar
Should be Empty: