Employer Referral Form

To refer an employee to ProHealth Care for a medical evaluation, treatment of a workplace injury or a drug screen, please complete and submit the form below. If you choose to download and print the form, please have your employee bring the completed form with him or her to a ProHealth occupational health services site.

PLEASE NOTE: This form is for employers to complete when sending an employee to ProHealth occupational health services for care.

To schedule a patient appointment, please call 262-928-5900.

Thank you.

1 + 9 =  Solve This To Prove You are a Real Person, not a SPAM script.
these hidden items are needed for ajaxeditor and ajaxslider otherwise they only work if they are on the first page of the form