SCHEDULE AN APPOINTMENT Fill out the form below and our customer service team will schedule and confirm your appointment within 24 hours. If you need an appointment ASAP, call 212-695-5122 and a customer service team member will ensure you’re taken care of. "*" indicates required fields 1 Personal Information 2 Appointment 3 Confirmation Please fill out the following information:First Name* Last Name* Email* Phone Number*Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer Name* Job Title/Position* Please fill out the following information:Appointment Location*Select a LocationManhattanBrooklynBrooklyn-MidwoodBronxQueensStaten IslandHempsteadAppointment Date (Mon.-Fri.)* MM slash DD slash YYYY Appointment Time7:30am8:00am8:30am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm5:30pm6:00pm6:30pmServices Requested* Pre-Employment Exam 10-Panel Drug Screen PPD (TB Test by Skin Induration) Annual Exam DOT/CDL Physical QuantiFERON (TB Test by Blood) History & Physical DOT/CDL Drug Test Measles Titer Mumps Titer Rubella Titer Varicella Titer Varicella Vaccine Other (Please specify below) Service Requested DescriptionWould you like to use insurance for this exam?* Yes No Choose your insurance plan:* 1199 Empire Blue Cross Blue Shield Emblem Aetna Cigna MagnaCare MultiPlan I don't have any of these plans Please enter your Member ID:* Consent* I acknowledge that my appointment is not confirmed until I speak with a customer service representative. CommentsThis field is for validation purposes and should be left unchanged.