This form is intended for employers who want to open an account with Doctors R Us Walk-In Clinic or Kenaday Medical Clinic for Occupational Medical services. Once we have confirmed the information, you will receive via fax a confidential reference number which will be used for service billing purposes. Any questions, contact Ilka Acosta at: (813) 890-0705 or Kenaday Medical Clinic at: (813) 935-6051.  The fields marked with (*) are required fields. * How did you hear about us? Referral Source: * Friend * Relative * Co-worker * Insurance Carrier Internet: * MSN Search * Yahoo Search * Google Search * Citysearch * Verizon Superpages Radio Advertisement? TV Advertisement? Flyer Advertisement? * Company Name:  * required * Contact Person:  * required * Title/Position:  * required   Address Line 1:   Address Line 2:   City:   State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington West Virginia Wisconsin Wyoming   Zip Postal Code: * Telephone Number:  * required * Fax Number:  * required   Type in the Business Email Address:   Indicate Tampa Location: Address, Telephone, Contact Person and number of employees:   Physical Examination: Employment Physical * Basic * Intermediate * Executive DOT Certificate Fitness-for-duty International Travel Independent Medical Other: ____________________________   Vaccines and Ancillary Services: Tuberculosis test Laboratory: _______________________ Vaccination: * Tetanus * Hepatitis B * Flu Other: ___________________________ Urine Analysis EKG (heart) Spirometry (lungs) X-ray w/written referral X-ray w/office visit for physician referral   Drug Free Workplace Testing (ID Required): DOT 5-panel FL DFW 5-panel FL DFW 8-panel FL DFW 9-panel FL DFW 10-panel Blood Alcohol Collection only: ______________________________ Rapid Drug Screen (No MRO)   Please indicate whether you want us to use your DFW forms?
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