Protocol Location

Is this protocol companywide or site/ area specific? *

Company Information:

Any dba’s, acronyms, sister companies, etc. that may be commonly used by your company when calling in for service? *
Company Address:*

Billing Information:

Billing Contact Name:*
Would you like to add an additional Billing Contact?
1 Billing Contact Name: *
Would you like to add an additional Billing Contact? 2
2 Billing Contact Name:*
Would you like to add an additional Billing Contact? 3
3 Billing Contact Name:*
Preferred Billing Method?*
Physical Address:
Is a PO or Job Number Required?

*Disclaimer: We are a fee-for-service only. We send invoices via email to the designated contact(s) listed above. Our payment terms are Net 30. All accounts will be subject to credit hold for invoices more than 60 days past due. All invoices will incur a late fee of 2% after 30 days past due, 3% after 60 days past due, with an additional $20 collection fee after 90 days. All miscellaneous site fees, including but not limited to parking expenses, ferry fees, badge fees, etc. will be billed as a straight reimbursement to the customer.  All site visits have a $85.00 minimum fee.  If we are scheduled after hours (after 5pm and before 6am on weekdays, or anytime on weekends or holidays), add $225.00 for California, Washington, and Massachusetts and add $215.00 for all other states to the total price of the visit.

Reporting Information (Who will receive all reports):

Type of Report:*
Name (1):*
Would you like to add additional reporting contacts?
Type of Report 1:
Name (2):
Would you like to add additional reporting contacts? (2)
Type of Report 3:
Name (3):

HR Representative Contact

Contact Name

Protocol Information

Services:
Check all that you're interested in!
Post-Accident Drug Screens
Check all that apply!
DOT (PA)
Is breath alcohol testing needed? (PA)
Non-DOT (PA)
Testing Kit (NPA)
Immediate Kit (NPA)
Collection Kit (NPA)
Is breath alcohol testing needed? (NPA)
Random Drug Screens:
Check all that apply!
DOT (RD)
Is breath alcohol testing needed? (RD)
Non-DOT (RD)
Testing Kit (RD)
Immediate Kit (NRD)
Collection Kit (NRD)
Is breath alcohol testing needed? (NRD)
Pre-Employment Drug Screens:
Check all that apply!
DOT (PED)
Is breath alcohol testing needed? (PED)
Non-DOT (PED)
Testing Kit (PED)
Immediate Kit (NPED)
Collection Kit (NPED)
Is breath alcohol testing needed? (NPED)

Respiratory Services

Will you always have the same masks?

Wellness Screenings

Additional Info

Please select all other services you are interested in.
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