Wufoo

Online Account Set Up

It's easy to get started with HealthWorks Northwest. Just fill out this online account set up form and you will be ready!

Today's Date * / MM / DD YYYY
Company Information

Tell us about your company.
Your Company Name *
Company Physical Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Company Billing Address (If Different)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - (###) - ### ####
Fax - (###) - ### ####
Web Site
Contact Information

Tell us whom we should contact for questions and information.
Primary Company Contact * First Last
Whom will we notify with results?
Primary Contact Phone Number * - (###) - ### ####
Alternate Phone Number - (###) - ### ####
Got a cell phone? Can we have it so we may contact you if you are not available at the office?
Primary Contact Email Address
Alternate Company Contact First Last
Is there someone else we can contact if the Primary Contact is not available?
Alternate Contact Phone Number - (###) - ### ####
Alternate Contact Email Address
How Can We Help You?

Tell us which of our many wonderful services you would like us to provide for you!
Our Many Wonderful Services
Drug Screens Breath Alcohol Tests Hearing Tests Respiratory Protection (Including Respirator Certifications and Fit Testing) Physical Exams DOT Physical Exams Injury Care First Aid/CPR Training

Tell us which of our many wonderful services you would like us to provide for your wonderful company!
Drug Screen Protocols *
DOT (Federally-regulated employees) Non-DOT (You can use our rapid results testing) Collection Only (You have a third party managing your drug screens) None of the above choices pertain to our company

Tell us which drug screen protocol(s) you will need.
Special Instructions

Here is where you tell us which laboratory you need to use (If you already have one set up). If you are not set up with any laboratory or Medical Review Officer (and even if you don't even know what these are, don't worry), we can help. Just leave this area blank and we'll set you up with our lab and our Medical Review Officer. Don't worry. We've got your back!
Results and Information Reporting

How would you like us to report results to you or to send you important documents?
Results Reporting *
e-Reports (I log into my confidential member area online and retrieve my results) Mail me my results Please call me with my results
That's It! You're Done.

Dont' forget to click the SUBMIT button!
Do Not Fill This Out

Wufoo

Online Account Set Up

Company Information

Contact Information

How Can We Help You?

Results and Information Reporting

That's It! You're Done.