EMPLOYER ACCOUNT PROTOCOL FORM

You may choose to complete the Employer-Account Protocol Form below which when completed will be forwarded to one of our Medical Assistants for Review.

This form is in 3 parts - Please complete ALL PARTS!

If you prefer, you can click on the button below which will open a FILLABLE PDF File - complete this form, print it, and email it to aruiz.ihmg@gmail.com

Click Here to access the Employer account protocol form

Employer Account Protocol Form PART 1

Employer Account Protocol Form

Company

Mailing Address

Primary Contact Person

Secondary Contact Person

Email*

Telephone Number

Fax Number

Hours of Operation

BILLING INFORMATION

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Industrial Health Medical Group

49305 Grapefruit Boulevard, Coachella, California 92236, United States

(760) 398-0723

Employer Account Protocol Form PART 2

Email*

Injury/Accident To The Employee:

Post Injury/Accident Drug Test: (Y/N)

Post Injury/Accident Breath Alcohol Test: (Y/N)

Pre-Employment Screening: Choose 1 for REGULAR; 2 for DOT; 3 for SPECIAL PACKAGE

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Industrial Health Medical Group

49305 Grapefruit Boulevard, Coachella, California 92236, United States

(760) 398-0723

Employer Account Protocol Form PART 3

Email*

Pre-Employent Screening (continued)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Industrial Health Medical Group

49305 Grapefruit Boulevard, Coachella, California 92236, United States

(760) 398-0723

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Industrial Health Medical Group

49305 Grapefruit Boulevard, Coachella, California 92236, United States

(760) 398-0723

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