Company Information

New Company Setup

ASPIRUS BUSINESS HEALTH
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Contact*

First NameLast Name
Title*
Phone Number*

Area CodePhone Number
Extension (if applicable)
Fax Number

Area CodePhone Number
Email*
example@example.com
Employee Count
Is billing information the same as above?*

YESNO
Billing Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Contact

First NameLast Name
Title
Phone Number

Area CodePhone Number
Extension (if applicable)
Fax Number

Area CodePhone Number
Email
example@example.com
Is the customer set up with a lab?

YES (customer supplied COC)NO (use Aspirus lab, paperwork, kits)
Designated Employer Representative (DER)

First NameLast Name
Title
Phone Number

Area CodePhone Number
Extension (if applicable)
Fax Number

Area CodePhone Number
Email
example@example.com
Results Handling

Secure EmailSecure FaxTPA (Third Party Administrator)iSystoc (Electronic Resulting)
Company Work Comp Contact

First NameLast Name
Phone Number

Area CodePhone Number
Extension (if applicable)
Fax Number

Area CodePhone Number
Email
example@example.com
WC Insurance Carrier
Additional Information
Please check ALL services requested.
Reason for Visit

Pre-EmploymentReturn to DutyPost-AccidentFollow-UpReasonable SuspicionRandomOther
Workers' Compensation

Injury Evaluation & Treatment Including Blood Borne Pathogen
Type of Test

Urine Drug TestObserved Drug TestDOT (Send Out)NON-DOT (Send Out)Aspirus Provided CCFCompany Supplied CCF (Collection Only)
Pre-Employment Screenings

Communicable DiseaseRespirator PhysicalDOT PhysicalTB Skin TestFirefighter PhysicalIshihara 12 Plate Color VisionHazmat PhyscialNear VisionPre-Employment Physical with Snellen VisionFly Stereo-Depth PerceptionPre-Placement Screen-TherapyPulmonary Function Test (PFT)Other
If Non-DOT, select option below:

5 Panel10 Panel
Onsite Rapid Testing

4 Panel5 Panel9 Panel10 Panel12 PanelDOTBreath Alcohol TestNon-DOTOther
Vaccinations

Hep ATetanusHep BVaricellaMMRFlu VaccineTDAPOther
Labs

Hep A TiterVaricella TiterHep B TiterQuant GoldMMR TiterLead Blood DrawTDAP TiterZinc Protoporphyrin ZPPOther
Annual Screenings

DOT RecertificationAnnual Physical ExamHazMat PhysicalRespirator QuestionnaireRespirator PhysicalAudiogramRespirator Fit TestingOther
Should be Empty:

New Company Setup