CLINIC: University of Illinois-Occupational Health Service Institute
835 South Wolcott (across from Student Center) Room E-144 Chicago, Illinois 60612 For appointments: 312-996-7420 FAX: 312-413-8485 Hours: M, T, TH, F: 7:00am – 4:00pm W: 7:00 am – 3pm STUDENT REGISTRATION FORM Photo ID required for all visits! CHECKS ONLY accepted
NAME:______________________________College of _____________ SS #: __________________________ D.O.B: _________________ Mailing Address: _____________________________________ City: ____________________State:___________ Zip ________ Email: ____________________________Cell: ___________________
Purpose of Visit:
CPT
Hep B S AB Hep B Antigen Hep B Vaccine Hepatitis C AB MMR Vaccine Measles Titer Mumps Titer Rubella Titer TB skin test TB Quantiferon TD TDaP Varicella Titer Varicella Vaccine Respirator Certification Urine Drug Test Form Completion Only 87430 87340 90746 86803 90707 86765 86735 86762 86580 86480 90718 90715 86787 90716
Charge
$20.00 $37.00 $63/ each $28.00 $77.00 $20.00 $22.00 $20.00 $25/ each $45.00 $46.00 $66.00 $20.00 $110.00 $35.00
TOTAL
10-Panel
$37.00 $10.00
09/15/08
TOTAL _______ Check # ____