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New Account Setup

MOBILE

251.434.6770
2050 Michigan Avenue
Mobile, AL 36615

PASCAGOULA

228.762.4642
5912 Old Mobile Ave., Ste. 1
Pascagoula, MS 39581

MOUNT VERNON

251.265.1215
950 E. Coy Smith Hwy
Mount Vernon, AL 36560

Location

Mobile Pascagoula Mount Vernon

Business Name

Physical Address

Billing Address

Business Phone

Fax Number

Contact Person

Job Title

Phone

Email

Cell

Secondary Person

Job Title

Phone

Email

Cell

Designated Employee Representative

Phone

Email

Cell

Results Reporting* - Please list names and email addresses of everyone who will need access to exam/test results:

Name

Email

Name

Email

Name

Email

Name

Email

Name

Email

*All results are reported through the PureOHS Employer Portal. Activation emails will be sent to each individual who needs access to the Portal within 48 hours of account setup.

Workers' Compensation Information:

Do you require drug test and/or breath alcohol test?

Yes No

If Yes, which type?

Where do you want us to send your workers’ compensations bills?

Company Insurance

Billing Information

Special Instructions

Physical:

Non-DOT DOT Physical Coast Guard OGUK/UKOOA FAA

Drug Tests:

Rapid 5 Panel Rapid 10 Panel Non-DOT 5 Panel Non-DOT 10 Panel DOT Drug Screen Hair Analysis (Our COC) Drug Screen Collection Hair Collection Oral Fluid Collection

Breath Alcohol Test:

Non-DOT Breath Alcohol Test DOT Breath Alcohol Test

Respirator Testing:

Pulmonary Function Test OSHA Respirator Medical Questionnaire/Clearance Fit Testing

Mask Type/Make/Model:

Other Testing:

Audiogram Vision Testing EKG Chest X-ray Lumbar X-ray

Lab-Based Testing:

OHC Lab Requisitions Company Lab Requisitions CBC Chemistry Profile Lipid Profile Hemoglobin A1C Urinalysis w/ micro TB Skin Test Quantiferon TB Gold Other (list below)

List Other Testing:

COVID-19 Testing:

Rapid COVID Test Standard PCR STAT/Expedited PCR

Immunizations/Vaccines:

Influenza Hepatitis A Series Hepatitis B Series Tdap Varicella MMR Overseas travel immunizations (Based on CDC recommendation - list below) Other Vaccines (list below)

List Other Immunizations/Vaccines:

Other Services not listed above:

QUALITY OCCUPATIONAL CARE

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