PH / Address
Results
|
Book An Appointment
Toggle navigation
MENU
Home
About Us
Our Services
Drug Testing
Alcohol Testing
Audio Testing
Mask Fitting
Medical/Nurse Assessment
Vision Testing
Spirometry Testing (PFT)
Price Lists
Lab Based Drug Test
Resources
Drug Information
Addiction Treatment
New Client Information Form
Careers
Contact Us
Edmonton
(780) 487-8355
Fort McMurray
(780) 790-1313
Grande Prairie
(780) 402-8685
All Locations >>
1 (877) 880-0737
OPEN
24/7
OPEN
24/7
Previous
Next
New Client Information Form
Legal Company Name:
*
Billing Information
Attn:
*
Billing Address:
*
Billing City:
*
Billing Province:
*
Billing Postal Code:
*
How would you like to receive your company’s invoices?
*
Email
Fax
Main Contact
Name:
*
Position:
Phone:
Fax:
Email:
Further instructions required by your company, please comment below:
Preferred method(s) of receiving results.
Website
Email Only
Email with attached result
Fax
Other
If result to be reported by email/fax please provide the information below.
Email
Fax
In case of a positive result during after-hours, who should be contacted or is an email sufficient?
Name:
Phone :
Other - Please specify:
If result is POSITIVE, would you like us to send it for confirmation to GAMMA – DYNACARE?
Yes
No
Check below for other services needed:
Audiometric Testing
Vision Test
Spirometry Testing
Mask Fitting
Panel 10
Other
Mask Type:
North Half
North Full
3M Half
3M Full
Scott 2000
Scott 3000
Other
Name:
*
Position:
*
*
indicates a required field.
Date:
*
Please sign above using your finger or soft tipped stylist.
