New Customer Form

New Customer Set-Up Form

Customer Name

Any dba's, acronyms, sister companies, etc. that may be commonly used by your company when calling in for service?

Yes

No

Site Address

Billing Contact Name

Billing Contact Phone Number

Phone *

Billing Contact Email Address *

Company EIN Number

Billing Address

Preferred Billing Method

Pay Via Credit Card (3% Added Fee)

Mailed to Job-Site Address

Mailed to Billing Address

E-Mailed to Billing Contact

PO Number

Injury Reports Contact Name

Injury Reports Contact E-Mail

Substance Abuse Testing Results Contact Name

Substance Abuse Testing Results Contact E-Mail

First-Aid Injury Treatment

Rapid Response First-Aid Treatment

Treatment Follow-up

Treatment Follow-up (Telehealth)

After Hours Possible

Drug / Alcohol Testing

Drug Screening (Include collection, Lab, and MRO)

Breath / Alcohol Screening

After-Hours Possible (6p-6a)

Add any comments needed for your Site.

Customers Signature

Date