Add or Update a Clinic Location

Location Title*

Location Address*

Street Address Address Line 2 City State ZIP Code

Services You Offer

CDL / DOT Physical
DOT Alcohol Testing
DOT Drug Testing
Merchant Mariner Exams
School Bus Exams
FAA Physicals

Other Key Services?

Office Hours*

Days You Are Open?*

Open Monday
Open Tuesday
Open Wednesday
Open Thursday
Open Friday
Open Saturday
Open Sunday

Monday Open*

:

Monday Closed*

:

Tuesday Open*

:

Tuesday Closed*

:

Wednesday Open*

:

Wednesday Closed*

:

Thursday Open*

:

Thursday Closed*

:

Friday Open*

:

Friday Closed*

:

Saturday Open*

:

Saturday Closed*

:

Sunday Open*

:

Sunday Closed*

:

Your Website

Office Phone Number*

Office Fax

Office / Contact Email

Examiner Full Name and Title*

Examiner Type*

Enter the Other Examiner Type*

National Registry Number*

Certification Date*

Consent*

I agree to the terms and conditions of Pass My Physical

I also agree that the information submitted here is accurate and complete and I also want it updated or added to the Pass My Physical system.

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