Customer Request

Customer Request/Order Form: Do you have a current contract with Medical TEMPS, Inc? If YES, please completely fill out all sections below and submit it directly to Medical TEMPS, Inc. If you do not have a current contract with Medical TEMSP, Inc. or are unsure if a contract is currently in place, please do not complete this form. Instead, please contact Medical TEMPS, Inc. directly at 318-651-4455 in order to receive a free quote of our services or to ascertain whether your contract is current.

Facility Name *

Person Placing Order for Facility *

Position with Facility *

Facility Address
Please include P.O. Box, Street Name, City, State and Zip Code

Facility Phone Number *
Please include area code and extension

Facility Fax Number
Please include area code and extension

E-mail Address *

Contact Phone Number If Different Than Facility Phone Number
Please include area code and extension

Medical Staffing Requested

Date(s) Needed

Special Considerations/Needs/Skills Needed To Fill Shift

Shift/Times Needed

If more than 1 (one) medical staff are needed or mutiple shifts are requested, please use the following space to record all of your staff, dates, shifts needed

Thank you for your request for medical staffing from Medical TEMPS, Inc. If a member of management does not contact you from Medical TEMPS, Inc. within 24 hours regarding your request, please contact us directly at 318-651-4455, 24 hours a day/7 days a week. Thank you for your business!

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