Mobile Online Estimation ToolPrisha Patel2021-11-03T16:14:46-06:00 Step 1 of 3 33% Name(Required) First Last Phone(Required)Email(Required) Company Name(Required) Company Position(Required) Company Address(Required) Location of Testing Number of KM from Hines Health Services headquarters (one way)(Required) Occupation Health Services(Required) Audiogram Mask Fit Testing Nurse Medical Spirometry Vision Screening Drug and Alcohol Testing Services(Required) Breath Alcohol Concentration (BAC) Drug Testing What dates would you like to book testing services?Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY How many employees require an audiogram?(Required)How many employees require mask fit testing?(Required)Which mask(s) do you required to be fitted?(Required) N95 Half Face Mask Full Face Mask Self Contained Breathing Apparatus (SPCA) Which model of N95 mask do you currently use? (Optional) Half Face Mask(Required) North 3M Other Full Face Mask(Required) North 3M Other Self Contained Breathing Apparatus (SPCA)(Required) Scott AV-2000 Scott AV-3000 Other How many employees require nurse medical?(Required)How many employees require spirometry?(Required)How many employees require vison screening?(Required)How many employees require breath alcohol testing?(Required)Drug Check(Required) Urine Oral Fluid Urine Check(Required) POCT (Express Test) Direct to Lab POCT (Express) and direct to lab Urine POCT(Required) 7 Panel 8 Panel 12 Panel Other Urine LAB(Required) 7 Panel 8 Panel 12 Panel Other URINE POCT and LAB(Required) 7 Panel 8 Panel 12 Panel Other Oral Fluid Check(Required) POCT (Express Test) Direct to Lab POCT (Express) and direct to lab Oral POCT(Required) 6 Panel Oral LAB(Required) 6 Panel 7 Panel 8 Panel 12 Panel Other Oral POCT and LAB(Required) 6 Panel 7 Panel 8 Panel 12 Panel Other
