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P. 419.720.2273

3065 W. Bancroft, Toledo, OH

Open Every Day 8am to Midnight

Urgent Care
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Weight Loss
Aesthetics
IV Therapy
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Company Information

Company Name *

Primary Contact Person *

Title/Role *

Phone Number *

Email *

Billing Address *

Services Requested *

Pre-Employment Physical

DOT Physical

Return-to-Work Evaluation

Workers' Compensation Injury Care

Drug Screening (5-Panel, 10-Panel, Rapid Test)

Vaccinations (Hep B, Tdap, Flu, Other)

TB Testing

Other Occupational Service

Authorization & Billing

Billing Contact *

Billing Email *

Billing Phone *

Preferred Billing Method *

Email

Mail

Drug Screening & Testing Information

Authorized to Send to Employer? *

Yes

No

Results Sent to (Name/Email/Phone) *

Workers' Compensation Information

Insurance Carrier *

Adjuster Name *

Adjuster Phone *

Adjuster Email *

Additional Notes or Special Instructions

Agreement

Authorized Representative Name *

unity-urgent-care-pharmacy-toledo-ohio

3065 W. Bancroft, Toledo, OH 43606

419-720-2273

©2026 Unity Urgent Care & Pharmacy

Urgent Care
Pharmacy
Weight Loss
Aesthetics
IV Therapy
Schedule an Appointment

Let’s talk

419.720.2273

info@uucpohio.com