8300 N. Church Rd
Kansas City, MO 64158
Phone (816) 407-2300 Fax (816) 407-2301
CLIENT PROFILE SHEET
Name: ______
StreetAddress: ______
Street Address City, State, Zip
MailingAddress: ______
(if different) Mailing Address City, State, Zip
Type of Business ______Hours______# of employees______
Primary ContactPerson: ______Title______
Phone: ______extension______Fax: ______
Cell: ______E-mail:______
Secondary Contact Person: ______Title______
Phone: ______extension______Fax: ______
Cell: ______E-mail:______
Insurance
Carrier: ______
Address: ______
Street Address City, State, Zip
Telephone: ______Fax: ______
Policy Number: ______Claims Representative: ______
(if known)
Send Workers’ Comp Injury Bills To: Company Insurance Carrier Other
Other: ______
Send Physical and Drug Screen Bills To: Company Insurance Other
Other: ______
Modified duty available No modified duty available
(Check preference) Fax work status E-mail work status Mail work status to:
Contact: ______ph:______
(Contact’s fax,e-mail or address):______
Post-accident breath alcohol testing: Always Upon request Never
Post-accident drug screen: Always Upon request Never
DOT
nonDOT Please mark type of nonDOT screen below:
Saliva
Hair
Urine - 5 panel 10 panel 10 panel quick screen*
*Quick screen NOT available for Saliva, Hair or DOT urine drug screens.
Post offer physical DOT FCE
Return to work Annual Caregiver physical
Respirator Fit for Duty Other______
Additional testing:
Audiogram Spirometry
Back evaluation TB
Resting EKG Treadmill
Chemistry profile Other laboratory______
Tetanus Flu
Use LH Urgent Care lab/MRO
LHUC generic Chain of Custody Company Specific Chain of Custody
Collection only, Company Specific Chain of Custody -use this Lab______
Employee brings in form and kit LH Urgent Care has company’s form and kit Courier Delivers
Report results by: Employer Portal E-mail Fax Phone Mail
Report to:
Contact: ______ph:______
Contact’s fax or e-mail:______
Please select the testing services below needed for your company.
Post offer:
DOT
nonDOT Please mark type of nonDOT screen below:
Saliva
Hair
Urine - 5 panel 10 panel 10 panel quick screen*
Breath Alcohol
Random:We are interested in LHUC managing our random pool. Yes No
DOT
nonDOT Please mark type of nonDOT screen below:
Saliva
Hair
Urine - 5 panel 10 panel 10 panel quick screen*
Reasonable suspicion: Direct Observation Required? Yes No Upon request
DOT
nonDOT Please mark type of nonDOT screen below:
Saliva
Hair
Urine - 5 panel 10 panel 10 panel quick screen*
Follow-up:
DOT
nonDOT Please mark type of nonDOT screen below:
Saliva
Hair
Urine - 5 panel 10 panel 10 panel quick screen*
Return to duty:
DOT
nonDOT Please mark type of nonDOT screen below:
Saliva
Hair
Urine - 5 panel 10 panel 10 panel quick screen*
*Quick screen NOT available for Saliva, Hair or DOT urine drug screens.