Business Health_Occ Health Service Request Form

Occupational Health Service Request

ASPIRUS BUSINESS HEALTH
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Extension (if applicable)
Email*
example@example.com
Employee Name

First NameLast Name
Specific Job Title*
Date of Birth

MonthDayYear
Date
Photo ID and Employer Chain of Custody are required to complete all drug/alcohol testing. Participant must be well-hydrated in order to give a urine specimen. If patient is under 18 years of age, parent or legal guardian consent is required.

Please print a copy of this form and provide to the participant to bring with them to the appointment.

AFTER HOURS TESTING: For post accident/reasonable suspicion-see additional after-hours form. You must supply the Chain of Custody at time of service.

Patient is here for the following test(s) - check all that apply

DRUG AND ALCOHOL TESTING
Reason for Visit

Pre-EmploymentReturn to DutyPost AccidentFollow-upReasonable SuspicionRandomOther
Type of Test

Urine Drug TestObserved Drug TestDOT (Send Out)Aspirus Provided CCFNON-DOT (Send Out)Company Supplied CCF (Collection Only)
If you selected NON-DOT Test, please check one of the below

5 Panel10 Panel
Onsite Rapid Testing

4 Panel10 Panel5 Panel12 Panel9 PanelBreath Alcohol TestOther
If you selected Breath Alcohol Test, please check one of the below:

DOTNON-DOT
LABS

Hep A TiterVaricella TiterHep B TiterLead Blood DrawMMR TiterZinc Protoporphyrin ZPPTDAP TiterQuant GoldOther
VACCINATIONS

Hep ATetanusHep BVaricellaMMRFlu VaccineTDAPOther
WORKERS' COMPENSATION

Injury Evaluation & Treatment Including Blood Borne Pathogen
PRE-EMPLYOMENT SCREENINGS

Communicable DiseaseTB Skin TestDOT PhysicalIshihara 12 Plate Color VisionFirefighter PhysicalNear VisionHazmat PhysicalPeripheral VisionPre-Employment Physical with Snellen VisionFly Stereo-Depth PerceptionPre-Placement Screen - TherapyPulmonary Function Test (PFT)Respirator PhysicalOther
Appointments can be made by calling Occupational Health at 715-847-2812.
- RHINELANDER – 1630 N Chippewa Dr., Suite B1604, Rhinelander, WI 54501
- PLOVER – 2401 Plover Road, Plover, WI 54467
- WAUSAU – 3200 Westhill Drive, Suite 2100, Wausau, WI 54401
- MEDFORD – 103 S Gibson Street, Medford, WI 54451
- LANGLADE – 112 E 5th Ave, Antigo, WI 54409
- WI RAPIDS – 410 Dewey Street, 2nd Floor, Wisconsin Rapids, WI 54494
- PORTAGE – 2815 New Pinery Rd, Portage, WI 53901
- HURLEY – 501 Granite Street, Hurley, WI 54534
Should be Empty:

Occupational Health Service Request

Appointments can be made by calling Occupational Health at 715-847-2812.