Skip to content

Onsite Medical Service, Inc

Home
About
Resources
Services
Hearing Sign in
- Confidential Hearing History Questionnaire
Scheduling
Customer Login
Online Respiratory Clearance
Contact

Onsite Medical Service, Inc

Home
About
Resources
Services
Hearing Sign in
- Confidential Hearing History Questionnaire
Scheduling
Customer Login
Online Respiratory Clearance
Contact

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

No

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

No

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

Would you be interested in Drug Testing?*

Yes

No

If "YES", how many?

Would you be interested in Health Physicals for your employees?

Yes

No

If "YES", how many?

Would you be interested in DOT physicals?

Yes

No

If "YES", how many?

Would you be interested in Silica testing?

Yes

No

If "YES", how many tests?

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

Vision Testing

Hearing Protection Fitting

Requesting Other Service

Not Needed

Comments & Concerns of Scheduling

CAPTCHA

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

ONSITE MEDICAL SERVICE, INC.
7990 69th Ave., Rockford, MN 55373
Serving Minnesota, Wisconsin, North Dakota, South Dakota, Iowa and More!

Office Hours: 8:00 a.m. to 4:30 pm
PHONE: 877-972-2281
FAX: 866-798-4692

©Onsite Medical Service, Inc. All Rights Reserved. | Privacy Policy | SEO and Website Designed by JJ Web Services. Thank You Veterans