Texas Med Clinic New Account Set-Up Form Page 3

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3
New Account Set-Up Form | SERVICES
Fax: 210.471.0217 | email:
Work Related Injuries:
Please check all that apply
 Modified Duty Available
 Company is under OSHA 300 Log
 Supervisor will bring employee to clinic
Drug Test Collection Only:
TMC will not be responsible for reporting results of drug tests to
Post Accident Collection Only
your company. TMC staff only collect the specimen. Employees
will need to bring in a CCF (Custody and Control Form) or
 Required  When requested
your consortium will need to mail CCFs to the clinic location. If
Pre-employment Collection Only
a CCF is not available, the employee will be turned away and
Random Collection Only
the collection cannot be performed.
For Cause Collection Only
Pre-Employment Drug Test
Random/For Cause Drug Test
Post Accident Drug Test
Hair Drug Test
Hair Follicle
 Required
 When requested
DOT
DOT
Hair Follicle
5 Panel Non-DOT
5 Panel Non-DOT
DOT
10 Panel Non-DOT
10 Panel Non-DOT
5 Panel Non-DOT
5 Panel Non-DOT, Expanded
5 Panel Non-DOT, Expanded
10 Panel Non-DOT
10 Panel Non-DOT, Expanded
10 Panel Non-DOT, Expanded
5 Panel Non-DOT, Expanded
5 Panel Rapid
5 Panel Rapid
10 Panel Non-DOT, Expanded
10 Panel Rapid
10 Panel Rapid
5 Panel Rapid
10 Panel Rapid
Breath Alcohol Tests
Physicals
Immunizations
Ancillary
Post Offer Physical
Hepatitis A
Tb test
Post Accident
DOT Physical
Hepatitis B
X-ray authorized for Tb Test
Required
Respirator Physical
TDaP
if needed
Chest x-ray
Hazardous Waste Physical
MMR
Random
Hearing Test
Asbestos Physical
Varicella
For Cause
Vision
Flu Shot
All Physicals will be performed
PFT/Spirometry
using Texas MedClinic’s forms
Respirator Fit Test
unless otherwise indicated
Other/Notes:

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