Transcription of BUSINESS HEALTH PARTNERS
1 BUSINESS HEALTH PARTNERSDATE _____COMPANY: _____ DATE:_____EMPLOYEE NAME:_____PO#:_____SS#: _____ POSITION:_____REQUESTED BY: _____ CONTACT#: _____REASON FOR TEST:(After marking your reason for test you will then need to select required testing below.)~PRE-ACCESS/ENTRY~PRE-EMPLOYMENT~ REASONABLE CAUSE~FOLLOW-UP~RANDOM~PERIODIC / ANNUAL~RETURN TO WORK~POST-ACCIDENT~OTHER _____LAB TESTSFIT TESTAUDIOMETRYDRUG SCREENS~SMAC / CBC (LIVER)~OSHA RESPIRATOR~NON DOT~DISA~CBC QUESTIONNAIRE (PFT Review)~DOT~URINALYSIS~PULMONARYFUNCTION ~HAIR TEST__5__10~BLOOD LEAD / ZPP~1/2 FACE _____~QUICK TEST__5__9__10~URINE PHENOL~ORAL FLUID~BLOOD BENZENE~FULLFACE _____~BASELINE~COMPARISONALCOHOLTESTING~ OTHER _____~NON DOT~DISA~DOT~SALIVA~BREATHPHYSICAL EXAM~DOT/CDL~BASIC EXAM~CRANE OPERATOR~COAST GUARD EXAM~RETURN TOWORK~FIT FOR DUTYOTHER SERVICES~EKG~CHEST X-RAY~1 VIEW~2 VIEW~LUMBAR X-RAY~2 VIEW~3 VIEW~5 VIEW~VISION (TITMUS)
2 ~JAEGER~ISHIHARA~IMMUNIZATION _____~OTHER _____SULPHUR3649 South Beglis Parkway Sulphur, LA 70665 Office (337) 626-1011 Fax (337) 558-5995 After Hours Contact:(337) 302-2011 DERIDDER1808 Hwy. 190 WestSuite C1 DeRidder, LA 70634 Office (337) 348-0842 Fax (337) 221-3033 BEAUMONT3749 Highway 69 NorthBeaumont, TX 77705 Office (409) 291-4858 Fax (409) 722-1823 After Hours Contact:(409) 527-1114 BAYTOWN3166 Decker DriveBaytown, TX 77520 Office (832) 514-3040 Fax (281) 422-3008 Port 8433
