May 12, 2023
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Pelican Urgent Care strives to provide you with exceptional service to ensure a positive, supportive encounter for you, your loved ones, and your employees.
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Billing Contact:
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Fax:
Email Invoices?
YesNo
Email For Invoices:
Main Contact for Urgent Service Related Questions:
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Email:
Services Needed:
DOT-CDLDOT-USSCGNon-DOT RoutineCrane OperatorReturn to Duty
DOT DS (Pelican as MRO)Non-Dot DS (Pelican as MRO)Rapid Screen-5 panelRapid Screen-10 panelDS Collection OnlyDOT Breath AlcoholNon-DOT Breath Alcohol
Lab:
OCC Med Services:
L-SpineChest X-RayAudioPulmonary Function TestAgility TestVision TestEKGTB Skin TestVaccinationsLab Testing
Other:
How would you like results sent to you?
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Company Name:
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Employee Name*:
SSN*:
Injury Date & Time:*
Fax #*:
Person Authorizing Treatment (Print Name)*:
Phone # of Authorizing Person*:
Coast Guard PhysicalNon-DOT PhysicalDOT PhysicalWorker’s Comp. InjuryTB Skin TestEKG Immunizations (TDAP, Hep A, Hep B, Tetanus/Diptheria, Flu, etc.)Respirator Clearance Exam with PFTLift TestAudiogramWeigh InChest X-RayWorker’s Comp. InjuryAgility TestLab Testing (CBC, CMP, Urinalysis, LIPID Profile, HIV, etc.)Chest X-RayVision TestL-Spine X-Ray
Other Testing Information:
Type
Non-DOT Urine Drug ScreenDOT Urine Drug ScreenDOT Urine Drug ScreenHair CollectionRapid/Onsite Urine Drug Screen5 Panel10 Panel
Reason
Pre-EmploymentPeriodicRandomFor Cause / SuspicionPost AccidentFollow upReturn to Work
Special Instructions
Life or Limb- Threatening Injuries – Dial 911
Non-Life or Non-Limb- Threatening Injuries – Dial (985) 645-9000
Follow-up care for an injury – Dial (985) 645-9000
