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Our Beaumont clinic location is closed today due to complications following Arctic Storm Enzo. All other Next Level clinic locations, including Nederland, are operating regularly and open until 9pm.  We look forward to caring for you! 

Treatment Authorization Form

Please complete the form before you arrive to the clinic for your appointment. If you have any questions or concerns, please email worx@nlucc.com or call 832-706-2295 so that we can assist you or your employee prior to the requested visit.

Employer Authorization Form
Patient Name:
Patient Name:
First Name
Last Name
Patient Address
Patient Address
City
State/Province
Zip/Postal
Company Address:
Company Address:
City
State/Province
Zip/Postal
Company Contact:
Company Contact:
First Name
Last Name
Billing Method:
Insurance Carrier Address:
Insurance Carrier Address:
City
State/Province
Zip/Postal
Pre-Employment Services Required?
Urine Drug Screening:
Physicals:
Breath Alcohol Testing (BAT):
Chest X-Ray Required:
Audiogram Required:
Urine Drug Screening:
Breath Alcohol Testing (BAT):
Please note that if our clinic will be performing a Physical, Chest X-Ray, or Audiogram unrelated to a work injury, walk-in appointments are not available.  A member of our team will contact the patient to schedule within one business day. 
Visit Method:

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