Applicant Scheduling

Please use the following form to request an appointment for your applicant(s).  This form should only be used if you have 5 or less applicants to schedule.  

If you have more than 5 applicants, please contact Stacy in our Special Services Department at 317.964.2355. All paperwork for your applicants will be completed at Public Safety Medical.  This includes the psych MMPI testing if applicable.

Based upon your request(s), we will e-mail you a schedule confirmation within 1 business day or will contact you to obtain any additional information needed.  Thank you.

Have you used Public Safety Medical in the past?
How did you hear about us? *

Your Applicant Results are sent to you via secure e-mail. Please contact Jane with questions at 317.964.2353.

Invoices Should Be Sent To:
Maximum upload size: 2MB
Number of Applicants to be Scheduled (up to 5)
If more than 5 applicants, please call Stacy in Special Services at 317.964.2355.
Please Use the Drop-Down List
Choose from drop down list
Results will be prepared within 10 business days of the appointment.
Please Indicate Type of Evaluation.
All services are performed in one location in one day.
Is this date at least 10 BUSINESS DAYS from the date you requested for the evaluation? *
Maximum upload size: 2MB
All Pre-Exam Paperwork and the MMPI testing (if applicable) is Completed at Public Safety Medical.
Applicant(s) can only pay by credit or debit card (if applicable)
Please Provide the Following Information on Each Applicant.
Enter First Name, Middle Initial, Last Name (If unknown, enter "Unknown")
Enter as MM/DD/YYYY
Enter First Name, Middle Initial, Last Name (If unknown, enter "Unknown")
Enter as MM/DD/YYYY
Enter First Name, Middle Initial, Last Name (If unknown, enter "Unknown")
Enter as MM/DD/YYYY
Enter First Name, Middle Initial, Last Name (If unknown, enter "Unknown")
Enter as MM/DD/YYYY
Enter First Name, Middle Initial, Last Name (If unknown, enter "Unknown")
Enter as MM/DD/YYYY
PLEASE CLICK "SUBMIT" AT BOTTOM OF SCREEN
STOP: PSM USE ONLY