Apr 03, 2024 Medical
by Johnny Amaraneni
Feb 20, 2024 Medical
Pelican Urgent Care strives to provide you with exceptional service to ensure a positive, supportive encounter for you, your loved ones, and your employees.
Full Name *
Upload Photo *Max file size 5MB Choose File
Your Testimonial *
Billing Contact:
Biiling Address:
City:
State:
ZIP:
Phone:
Fax:
Email Invoices?
YesNo
Email For Invoices:
Main Contact for Urgent Service Related Questions:
Office Phone:
Cell Phone:
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?
FaxEmail
Fax Recipient:
Fax #:
Email Address::
Company Name:
Address:
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