On-Site Request Form

This form is for companies wishing to schedule on-site testing at their facility for at least 5 test candidates.

This form must be submitted at least 2 weeks prior to any requested dates. Once a form is received and one of the requested dates is confirmed, a work order will be generated and emailed to the contact person designated on the form within 5 business days.

If you have any questions, please contact Tina Espinosa at tespinosa@vdnclinic.com or Monica Garza at mgarza@vdnclinic.com.

Company Information

Company Name*

Company Address*

Company Phone*

Company Fax

Contact Information

Contact Name*

Contact Phone*

Contact Email*

Billing Information

Billing Contact Name*

Billing Address*

Billing Phone*

Billing Fax

Requested Services Information

Requested Clinic Location *

Services Requested*

Estimated Date Requested*

Estimated Time of On-Site*

Approximate # of Employees*

I understand that filling out this form does not guarantee an On-site Testing Date. In the event that none of the preferred dates listed above are available, I understand that the Valley Day and Night Clinic Corporate office will contact me directly to let me know and I may have to fill out an additional request form.

I understand that failure to fill out this form correctly or completely may result in a delayed response from the Valley Day and Night Clinic Corporate office.

I understand that On-site Testing is reserved for companies/corporations with at least 5 employees prepared for testing on the scheduled date.

I understand that if our institution does not have enough eligible test candidates to schedule on-site testing, we can instruct them to schedule their individual exam appointments at any Valley Day and Night Clinic location. All test dates I have listed above are accurate and will be accommodated by our facility if confirmed.

 

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