CLIENT SET-UP FORM


Fill Out The Online Form Below.

OR

Print and Complete This PDF and Fax to Kootenai Occupational Medicine.

(208) 292-2959 Phone
(208) 292-2944 : Fax

Our Staff will contact you and build a protocol of the services you require.
 

Client Set-Up Form


 Work Related Injury Treatment
 Post-Accident
 Pre-Placement
 Random
 Random Pool Administration
 Reasonable Cause
 Instant Drug Screen
 NON DOT 5 Panel Drug Screen
 NON DOT 10 Panel Drug Screen
 Breathe Alcohol Test
 Saliva Alcohol Test
 DOT Physical
 Pre-Placement
 Other (please call for further information)
 TB Testing
 Chest X-Ray
 TDap (Tetanus)
 Hepatitis Vaccination Series
 Flu Shot
 Respirator Questionnaire
 Respirator Exam
 I would like someone to contact me for more information