Call Ahead Care Line: (281) 783-8162

Treatment Authorization Form

Please complete the form below before you arrive to the clinic for your appointment. If you have any questions or concerns, please email physicals@nlucc.com or call 281-895-3566 so that we can assist you or your employee prior to the requested visit.

Patient Name *

First

Last

SSN/ID # *

Date of Birth *

Patient Phone *

Company Name *

Company Phone *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Company Contact *

First

Last

Company Contact Email *

Company Contact Direct Number *

Company Contact Signature *

Please attach employee job description if available.

Click or drag a file to this area to upload.

Which region will the patient be testing in?

Who should we bill for this service? *

Employer (see address above)
Employee to pay at time of service
Workers Compensation (report injury to Insurance Company)

Pre-Employment Services: *

Work Injury Testing: *

Urine Drug Screening Needed? *

DOT
Non-DOT Instant Read
Non-DOT Send to Lab
Service Not Needed

BAT Needed? *

DOT
Non-DOT
Service Not Needed

Any Special Instructions?

There's More to Explore at Next Level!

Subscribe to be notified when we publish blogs, videos, press releases and more!

Subscribe to our Podcast

Tune into Health Xplained for up to date insights from real health care professionals!

Explore Episodes

We improve our services by using Microsoft Clarity to see how users interact with our website. By using our site, you agree that we and Microsoft can collect and use this data.

GET THE MOBILE APP

For fast and easy scheduling, download or open the Next Level mobile app! Click the icon below to get started.

Treatment Authorization Form

There's More to Explore at Next Level!

Subscribe to our Podcast

Patient Resources

Employer Resources

Additional information

GET THE MOBILE APP