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REQUEST TREATMENT

Do you or one of your employees have any symptoms consistent with COVID-19? Have you or your employees been exposed to a confirmed COVID-19 positive case? Prohealth offers COVID-19 rapid testing! Contact us today to set up an appointment to be tested in one of our clinics or for information regarding on-site testing.

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Employer Request For Treatment

To be filled only by authorized manager

Employee Name

Employee Phone

Employee DOB

Job Description

Date/Time of Injury

Injury

Company

Manager Name

Employer Address

Employer Phone

Employer Fax

WC Ins. Policy #

WC Ins. Address

WC Ins. Phone:

Modified WK Available?
No Yes

Service Requested
New Injury
Spirometry PFT
NIDA Drug
Return To Work
PPD (TB Test)
Non-NIDA Drug
Pre-Emp Phys
Chest X-Ray
Breath Alcohol
DMV Physical
Hepatitis B Vac (Photo Required)
Audiometry
Other:

Preferred Location
Valley
Glendale
Bakersfield
Delano

Temporary COVID Hours:

Monday-Friday: 8:00AM-6:00PM

Saturday-Sunday: Closed

On-Call Available for Initial Injuries 24/7

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