New Customer or Update Form for Artesia Drug & Alcohol Screening Only

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Marty Petsonk Counseling

New Customer Account or Account Update

Date

Company Name

Office Phone:

Contact 1:

Phone:

Contact 2 (if none enter n/a):

Phone:

Physical Address (Street, City, State, Zip):

Mailing Address (If Same as Physical Address Skip to Next Question):

Company eMail:

Company Fax:

Do You Use "Form Fox"? If So, Please Enter Your Account Number:

Services Requested:

DOT u/a

non-DOT u/a

Breath Alcohol (EBT)

Hair

Rapid Test u/a

non-DOT SALIVA

Use Your Lab?

Yes

No

Name of the Lab You Use:

"Other" - Enter Name of Lab

Account Nuber of Your Lab

Your Medical Review Officer Name (If none go to "Invoice To if Different Than Company Name:":

MRO Phone:

MRO Fax:

MRO Mailing Address:

MRO eMail:

Line Space

Invoice To if Different Than Company Name:

Billing Address:

Billing Contact:

Phone:

eMail:

Fax

Special Billing Instructions?:

Free Text

List below how you would like to receive invoices: Examples: eMail, Regular Mail, Fax, Other Instructions:

List

Info Wanted on Invoice:

Name

Name:

SS#:

Employee ID#

Employee ID#:

Reason for Test:

Specimen ID#:

Line Space

Are You a Member of a Testing Consortium (C/TPA)? If YES, Provide Consortium Name:

C/TPA Contact Person:

C/TPA Mailing Address:

C/TPA eMail Address:

C/TPA Phone:

C/TPA Fax:

Line Space

Line Space:

Would You Like Information on Joining Our Consortium?

Yes

No

Thank you for contacting us.
We will get back to you as soon as possible. Any questions or problems with this form, please call (575) 746-3404.

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New Customer Account or Account Update

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