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Covid 19 Testing Done Here
FAX: Urgent Care: (541) 389-4096 Occupational Health: (541) 317-0533
541-388-7799
Bend's First and Finest
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1302 NE 3rd Street
Bend, Oregon 97701
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Occupational Health Services Contract
Mountain Medical Fax (541) 389-4096
Company Name
(Required)
Date
MM slash DD slash YYYY
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(Required)
Street Address
Address Line 2
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Afghanistan
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Phone
(Required)
Primary Company Contact/DER Email
(Required)
What method of notification would you like for your results?
(Required)
Telephone/VoiceMail
Encrypted Email
Fax ( will use Fax numbe rabove)
US Mail (will use mail address above)
Authorized Signature
(Required)
Payment is due upon receipt of invoice; all remittance must include a statement number.
Drug and Alccohol Services Requested
Health Services Contract
4 Panel: $37.00 (Amphetamines, Alcohol, Cocaine, Amphetamines, Opiates, Barbiturates, Phencyclidine, (PCP/Angel Dust)
5 Panel: $40.00 (Amphetamines ,Marijuana ,Cocaine ,Methadone, Marijuana, Methaqualone Opiates, Opiates, Phencyclidine, (PCP/Angel Dust)
9 Panel: $45.00 (Alcohol, Amphetamines, Barbiturates, Benzodiazepines,Cocaine, Ecstasy,Marijuana ,Opiates, Phencyclidine (PCP/Angel Dust)
12 Panel: $50.00 (Alcohol,Amphetamines, Barbiturates, Benzodiazepines,Cocaine, Ecstasy,Marijuana ,Opiates, Phencyclidine (PCP/Angel Dust), Methadone, Methaqualone,Propoxyphene
DOT 5 Panel: $55.00
Medical Review: $40.00
EtG Only: $50.00
Oral Mouth Swab: $50.00 (5 Panel)
Breath Alcohol: $35
Breath Alcohol Confirmation: $20
1. For what reasons would you like drug/alcohol testing provided? (i.e. pre-employments, CDL Consortium, reasonable suspicion and/or post accidents?)
(Required)
2. Are we to do a different drug panel for different reasons of testing (i.e. 5 panel for pre- employment but 12 panel for post-accident)?
(Required)
What protocols do you want in place for the following situations?
Shy Bladder
Out of Temp Urine Specimen
Quantity not sufficient:
Other Services Requested
Choices
Hepatitis B antibody $20.00
Hepatitis B vaccination (per vaccine) $70.00
Back Evaluation $50.00
Manual Lift/Push and Pull test $60.00
Physician Physical Exam $100.00
PPD (TB Skin Test) $25.00
Quantiferon TB Gold test $110.00
Respiratory Fit test $100.00
Respiratory Questionnaire (OSHA) $25.00
Spirometry – Pulmonary Function Test $110.00
Venipuncture (collection only) $25.00
Venipuncture and Lab processing fee $45.00
Choices
Audiometry $70.00
Back Evaluation $50.00
Chest X-ray $150.00
DOT or NON DOT drug test collection only $20.00
DOT Physical $100.00
Drug screen collection Offsite Setup $40.00 plus FedEx fees
EKG w/interpretation $135.00
Flu vaccination $40.00
Hepatitis A antibody $20.00
Hepatitis A vaccination (per vaccine) $120.00
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