Total OccMed | New Client Account

If you would like to set up a new account, simply click the Online Account Set-Up link below. Or, print, and fax to our main office at (225) 927-0547.
Choose a location:
Company Name:
Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Contact Person:

First NameLast Name
Position at Company:
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Billing Information
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Accounts Payable Contact:

First NameLast Name
Worker's Comp. Insurance Address
Worker's Comp. Insurance Company:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Worker's Comp. Insurance Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Injury Treatment
Contact Person:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Post-Accident Drug Screening:
Post-Accident Breath Alcohol:
Services Requested
Breath Alcohol Test:
Pulmonary Function Test:
Respirator Fit Test:
Audiogram:
Additional Comments:
Should be Empty:

Billing Information