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Employer Referral Form

To refer an employee to ProHealth Works for a medical evaluation, treatment of a workplace injury or a drug screen, please complete and submit the form below. If you choose to download and print the form, please have your employee bring the completed form with him/her to ProHealth Works. PLEASE NOTE: ProHealth Works does not accept online appointment requests. This form is for employers to complete when sending an employee to ProHealth Works for care. To schedule a patient appointment, please call 262-928-5900.

Thank you.








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