Healthcare Screen Request Form

Please complete this form to request background and/or drug screens for candidates. Screens will only be ordered for candidates that have met the credentialing requirements and require completed screens prior to submission for assignment.

  • MM slash DD slash YYYY

  • Note: Multiple candidates with same assignment and request details can be added to this from by clicking the + symbol to add additional names.
    NameEmailPhone 
  • MM slash DD slash YYYY

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