subject_line
Collection Site Work Order
Date:
*
+
Company Name:
*
Examiner Information
EXAMINER #1
*
EXAMINER #2
Special Instructions
Date Ordered
*
+
Ordered By:
*
Phone #
*
Donor Information
Donor Name #1:
*
SSN#/ID#
*
COC#
EBT Test#
EBT Conf #
SCREEN TYPE
*
DOT
NON - DOT
DNA
MODE:
*
FAA
FMCSA
FRA
USCG
FTA
PHMSA
NON-DOT
REASON FOR TEST
*
PRE-EMPLOYMENT
RANDOM
POST ACCIDENT
REASONABLE CAUSE
FOLLOW UP
RETURN TO DUTY
PRIVATE
OTHER
Please Specify
*
Private Test $
*
No Show?
YES
Additional Donor?
YES
Donor Name #2:
*
SSN#/ID#
*
COC#
EBT Test#
EBT Conf #
SCREEN TYPE
*
DOT
NON - DOT
DNA
MODE:
*
FAA
FMCSA
FRA
USCG
FTA
PHMSA
NON-DOT
REASON FOR TEST
*
PRE-EMPLOYMENT
RANDOM
POST ACCIDENT
REASONABLE CAUSE
FOLLOW UP
RETURN TO DUTY
PRIVATE
OTHER
Please Specify
*
Private Test $
*
No Show?
YES
Additional Donor?
YES
Donor Name #3:
*
SSN#/ID#
*
COC#
EBT Test#
EBT Conf #
SCREEN TYPE
*
DOT
NON - DOT
DNA
MODE:
*
FAA
FMCSA
FRA
USCG
FTA
PHMSA
NON-DOT
REASON FOR TEST
*
PRE-EMPLOYMENT
RANDOM
POST ACCIDENT
REASONABLE CAUSE
FOLLOW UP
RETURN TO DUTY
PRIVATE
OTHER
Please Specify
*
Private Test $
*
No Show?
YES
Additional Donor?
YES
Donor Name #4:
*
SSN#/ID#
*
COC#
EBT Test#
EBT Conf #
SCREEN TYPE
*
DOT
NON - DOT
DNA
MODE:
*
FAA
FMCSA
FRA
USCG
FTA
PHMSA
NON-DOT
REASON FOR TEST
*
PRE-EMPLOYMENT
RANDOM
POST ACCIDENT
REASONABLE CAUSE
FOLLOW UP
RETURN TO DUTY
PRIVATE
OTHER
Please Specify
*
Private Test $
*
No Show?
YES
Additional Donor?
YES
Charges and Fees
Additional Fees & Services
IN Office
Mobile
Emergency Services
Direct Observation
Wait Time (mins):
15
30
45
60
75
90
120
Miles to Site:
Miles from Site:
Fee Per Mile:
Total:
0.00
Calculate
Collection Site:
*
MT Chemnet
Bozeman - Tri Med
Butte - Pro Med
Great Falls - GF Medical
Havre - Bullhook
Helena - Montana Work Care
Kalispell - Valley Medical
Lewistown - CMMC
Miles City - Dr. Stanley
Missoula - CMS
Missoula - Missoula Medical
Sidney - Blue Water
Casper, WY - Pioneer Testing
Boise, ID - The Wellness Center
Other
Tri-Med Services
2075 Charlotte St, Ste 1
Bozeman MT 59718-3551
Chemnet
1302 Ave D Suite 103
Billings, MT 59102
Pro-Med Services
505 West Park
Butte MT 59701
Great Falls Medical Services
1201 Central Avenue
Great Falls MT 59404
Beth Mindt
Blue Water Collections
222 2nd Avenue SW
Sidney MT 59270
Dr. Sheridan Jones
Montana Workcare
827 N Last Chance Gulch, Ste. B
Helena, MT 59601
Missoula Medical
1805 Bancroft
Missoula MT 59801
Bullhook Community Health Center
521 4th Street
Havre, MT 59501
CMMC Occupational Health
310 Wendall Ave Ste 2
Lewistown MT 59457
Dr. Dan Stanley
103 N 8th Street
Miles City MT 59301
Valley Medical
2425 Highway 2E
Kalispell MT 59901
The Wellness Center of Boise
Kieth Twigg
1675 North Maple Grove Rd.
Boise, ID 83704
Pioneer Testing Services, LLC
Kelli Epp
111 S Jefferson Ste 145
Casper, WY 82601
Compliance Monitoring Systems
2809 Great northern Loop Ste 100
Missoula, MT 59808
SITE NAME:
*
Street Address
*
City
*
State
*
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Hawaii
Idaho
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Indiana
Iowa
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Zip Code
*
Phone Number
*
Email Address
*
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Special Notes
Support
If you have additional questions or concerns, please feel free to contact us (406) 256-2037 or Email us at:
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