Drug & Alcohol Test and Medical Cert Request Form Please enter your name:(Required) First Last Enter your email address(Required) Select your location:(Required)Please selectCarrollCedar RapidsDes MoinesDubuqueKansas CityLas VegasLincolnOrlandoPhoenixRockfordSaint LouisSioux FallsPlease select(Required) Drug and/or Alcohol Test Medical Certificate BOTH Enter the name of the individual that will be taking the test/medical(Required) First Last Please add the City, State, Zip Code for the location of the test(Required) City State / Province / Region ZIP / Postal Code Enter the estimated date to be completed?(Required) MM slash DD slash YYYY DOT or Non-DOT Test?(Required) DOT - for drivers DOT FTA - for 380 & VIA drivers Non-DOT - for employees that do NOT drive Type of Test(Required) Pre-Employment Random Follow-Up Test For any other types of tests, a phone call must be made before the test is conductedPre-Employment Test Information(Required) Drug Test Only Random Drug Information(Required) Drug Test Only Alcohol Test Only BOTH Drug and Alcohol Test List any special circumstances for the test (must be on a Saturday; request for a specific location; etc)Submit this form and the authorization for the Drug/Alcohol test will be emailed to you through our DSI Medical SiteSubmit this form and the authorization for the Drug/Alcohol test will be emailed to you through our DSI Medical SiteCarroll - You must call Soppe's and make an appointment, they will receive a copy of this authorization when it is submitted. A copy of this authorization will be sent to Payables.Cedar Rapids - Submit this form for accounting and an appointment is required at the following location.Mercycare, 777 76th Ave Dr SW, Cedar Rapids - 319-558-0342Des Moines - Submit this form for accounting and an appointment is required at the following location.Fangman Family Chiropractice PC, 200 SE Gateway Dr Suite 103, Grimes, IA - 515-986-4003Dubuque - Submit this form for accounting and an appointment is required at the following location.Tri-State, 4155 Pennsylvania Ave, Duguque, IA - 563-584-4600Kansas City - Submit this form for accounting and an appointment is required at the following location.Liberty Hospital Urgent Care, 8300 N Church Road, Kansas City, MO - 816-407-2300Las Vegas - Submit this form for accounting and an authorization from DSI Medical will be emailed to you for the driver to take with them to the facility.Lincoln - Submit this form for accounting and send authorization with driver to the CHI Company Care Occupational Clinics we have set-up in Lincoln and OmahaLincoln - 5000 N 26th Street, Suite 200; Omaha - 5005 S. 153rd Street (153rd and Q)Orlando - Submit this form for accounting and an authorization from DSI Medical will be emailed to you for the driver to take with them to the facility.Phoenix - Submit this form for accounting and an authorization from DSI Medical will be emailed to you for the driver to take with them to the facility.Rockford - Submit this form for accounting and an appointment is required at the following locationPhysicians Immediate Care, 3475 S Alpine Road, Rockford - 815-874-8000St. Louis - Submit this form for accounting and an authorization from DSI Medical will be emailed to you for the driver to take with them to the facilitySioux Falls - Submit this form for accounting and an authorization from DSI Medical will be emailed to you for the driver to take with them to the facility
