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Please note if you do not have an active account you will be required to pay for service at the time of the visit or you can fill the following form and you will be contected within 1 business day so we can set up your account prior to sending in your employee for care.
I testify that the information in this form is accurate, and I authorize Medpost to treat patient as requested above.
Choose a Location:
Do you have an existing account?:
Company Contact First Name:
Company Contact Last Name:
Company Street Address:
Do you require Occupational Medicine services?:
Drug Screen Purpose (check all that apply):
Drug Screen Type:
Other Test Options (check all that apply):
Physicals (check all that apply):
Ancillary & Vaccines (check all that apply):
Please specify (required for X-Ray):
Do you require Worker's Compensation services?:
Please specify any other required services:
Enter your full name to sign:
Thanks for filling out this form!
Wait! Do you take my insurance? Who will see me? What will I owe? Not to worry — check out all of that here.