Occupational Medicine Interest Inquiry – CommunityMed Family Urgent Care

CommunityMed provides easy access to medical services for your business. This form allows you to inquire about services and pricing for your company. Please fill out the form below to receive proposed pricing for your staff.

"*" indicates required fields

Company Name*

Main Contact Name*

Main Contact Phone*

Main Contact Email*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What best describes your Company

Utilize Workman’s Compensation Insurance

Non-subscriber to workman’s comp

Neither

Please select the services you are interested in below:

Pre-Employment Physicals and/or Drug Screens

DOT Services

Work-Injury

Vaccines/Titers

Breath Alcohol Testing

Additional services you would like us to provide (please describe):