Client Scheduling Form

At Onsite Medical Service our mission is to exceed our customers expectations with the quality of the on-site testing experience and the 24/7 commitment to service you can count on from a family owned small business. To help serve you please fill out as much of the following information as you can.

"*" indicates required fields

Name*

Email*

Company Name*

City or Plant Location*

State*

Phone*

Billing Contact*

Billing Email*

Accounts Payable Contact (if applicable)

First Last

Accounts Payable Email (if applicable)

Are you a:

New Customer

Returning Customer

Is this your first time filling out our scheduling form?

Yes

What are the start and stop times of each of the shifts you run?

1st shift Times:

2nd shift Times:

3rd shift Times:

Other shift Times:

Please indicate how many employees on each shift need the different services we provide.

Example: Hearing test/ Medical Clearance for Respirator Use (PFT) / Respirator Mask Fit Hearing Test.

1st shift Employee Totals per shift:

Hearing Test:

Medical Clearance for Respirator Use (PFT):

Respirator Mask Fit Qualitative Test:

Respirator Mask Fit Quantitative Test:

Other:

2nd shift Employee Totals per shift:

Hearing Test:

Medical Clearance for Respirator Use (PFT):

Respirator Mask Fit Qualitative Test:

Respirator Mask Fit Quantitative Test:

Other:

3rd shift Employee Totals per shift:

Hearing Test:

Medical Clearance for Respirator Use (PFT):

Respirator Mask Fit Qualitative Test:

Respirator Mask Fit Quantitative Test:

Other:

Other shift Employee Totals per shift:

Hearing Test:

Medical Clearance for Respirator Use (PFT):

Respirator Mask Fit Qualitative Test:

Respirator Mask Fit Quantitative Test:

Other:

If we are providing hearing testing are we conducting the hearing conservation training?

Yes

If we are providing Respirator Mask Fit Testing please specifically indicate how many wear half face masks and how many wear full face masks on each shift and the mask make and models.

Dates not available to test

Contact names and numbers for early/late shifts

Do you have a need for information on vision testing or hearing protection fitting?

Vision Testing

Hearing Protection Fitting

Requesting Other Service

Comments & Concerns of Scheduling

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Thank you for choosing Onsite Medical Service Inc, we appreciate your business!