Southern Medical Corporation
Office: (225) 756-5239
​Hours: Mon-Fri, 8am-5pm
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    FMLA REQUEST FORM
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    Do not list company issued email addresses, personal email address only for privacy
    If you are requesting leave due to Coronavirus (COVID-19), please read the 6 eligibility reasons and list your qualification in the comments section of this form.
    Enter the estimated last day you will be available to work and/or be scheduled hours.
    How many weeks is estimated for medical leave (2 weeks, 8 weeks, 12 weeks, etc.)
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American Diagnostic Technologies (Mobile Nuclear, Stress & CPET Services)
Etech Medical Solution

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