Client Account Request | Oregon Occupational Medicine

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Thank you for your interest in Oregon Occupational Medicine. Please complete the pertinent sections in this form. If you have any questions please contact us at 503-563-5382. We look forward to providing excellent occupational medicine services to your company.

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Company Demographics
Company Name*
Physical Address
Street Address Address Line 2 City State ZIP Code
- Check if Billing Address is different from the Physical Address
Billing Address
Street Address Address Line 2 City State ZIP Code
Company Phone*
Fax
Primary Contact
Name*
Email*
Phone*
Notes

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Additional Company Contacts
Contact #2
Name
Title
Phone
Email
Contact #3
Name
Title
Phone
Email
Contact #4
Name
Title
Phone
Email

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Worker’s Compensation Insurance
Insurer
Phone
Policy Number
Address

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Injury Care
(acute injuries seen same day, provider will call you with employee’s work status)
Post accident drug screen on initial visit?
- Yes
- No
Breath Alcohol Test?
- Yes
- No
Additional Notes:

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Alcohol Testing
(No appointment needed, please send a service authorization form with your employee)
Type of Testing:
- DOT
- Non-DOT
Reasons for Testing:
- Pre-employment
- Post-Accident
- Reasonable Cause
- Random
Bill DS Collection to:
- Company as listed above
- TPA
- Other:
Other

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Drug Testing
(No appointment needed, please send a service authorization form with your employee)
Type of Testing:
(*Rapids are non-dot)
- DOT
- Non-DOT
- Rapid 6 Panel*
- Rapid 10 Panel*
Reasons for Testing:
- Pre-employment
- Post-Accident
- Reasonable Cause
- Random
Lab Name:
Account Number(s):
MRO Name:
Address
Street Address Address Line 2 City State ZIP Code
Phone
Bill DS Collection to:
- Company as listed above
- TPA
- Other:
Other

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Additional Services
(Appointments required, please send a service authorization form with your employee)
Physical Exams*:
- Pre-employment
- DOT
- Respirator Exam
- Respirator Questionnaire Review
- Audiogram
- Lift Test
- Other:
*Exams include basic vision, whisper and UA Dip
Other
Immunizations:
- Hepatitis A
- Hepatitis B
- Tetanus (Td/TDaP)
- Other:
Other
Additional Notes:

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Reports and Contact
How would you like your reports sent?
***Unless otherwise noted, all results will only be sent to the primary contact listed above.***
- Fax
- Mail
- Email, indicate password below
Secure Fax #
Desired PDF Password
Reports via secure email are sent as a password-protected PDF, write your preferred 4-8 character password
Signature
Full Name
Signature*
My signature below indicates that I have authority to request these services for the above named company. I understand my company's requested services may be updated at my (or a named contact's) verbal or written request. I agree to the standard fee rates charged by Oregon Occupational Medicine, unless another financial agreement has been made. I understand that all accounts are net 30 and agree that payment will be made on these terms.
Title
Phone
Phone
This field is for validation purposes and should be left unchanged.

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WORK INJURY CARE

Work Injury Care

DOT PHYSICALS

DOT Physicals

DRUG & ALCOHOL TESTING

Drug & Alcohol Testing

ADDITIONAL SERVICES

Physical Therapy

Ergonomic Assessments

Massage Therapy

Respirator Fit Testing

Work Strengthening and Conditioning

MEDICAL EXAMS

Immigration Exams

DOT Physical Exams

Fitness For Diving Examinations

Tualatin Clinic

19365 SW 65th Ave. Ste 100
Tualatin, OR 97062

Phone: (503)563-5382
Fax: (503)563-5392

[email protected]

Tualatin Physical Therapy

19365 SW 65th Ave. Ste 106
Tualatin, OR 97062
Phone: (503)563-5390
Fax: (503)563-5391

[email protected]

Hillsboro Clinic

1200 NE 48th Ave. Ste 1000
Hillsboro, OR 97124

Phone: (971)470-3275
Fax: (503)596-2182

[email protected]

Hillsboro Physical Therapy

4950 NE Belknap Court
Hillsboro, OR 97124

Phone: (503)563-5390
Fax: (503)563-5391

[email protected]

Tigard Clinic

9370 SW Greenburg Road,

The Commons Franklin Building, Ste 101

Tigard, OR 97223

Phone: (503)347-7366
Fax: (503)477-6853

[email protected]

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Please submit this form to apply.

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