Test Recipient
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Zip Code:
Date of Birth
*
-
Month
-
Day
Year
Date
Reason
*
Please Select
Probation
Pre-employment
Personal
Court Ordered
Other
Random
Post Accident
Reasonable Suspicion
Return to duty
Follow Up
Fit for duty
Reason for Test
Direct Observation Required?:
Only "yes" for probation
Quantity:
*
How do send the results?
*
Email
Fax
Email & Fax
Enter Valid Email:
*
Where should the test results be emailed?
Please include and additional info:
File Upload:
Browse Files
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Choose a file
Order forms, request forms, inquiries etc
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of
Add Another Test Recipient?:
Yes
No
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Zip Code:
Date of Birth
*
-
Month
-
Day
Year
Date
Reason
*
Please Select
Probation
Pre-employment
Personal
Court Ordered
Other
Random
Post Accident
Reasonable Suspicion
Return to duty
Follow Up
Fit for duty
Reason for Test
Direct Observation Required?:
Only "yes" for probation
Quantity:
*
How do send the results?
*
Email
Fax
Email & Fax
Enter Valid Email:
*
Where should the test results be emailed?
Please include and additional info:
File Upload:
Browse Files
Drag and drop files here
Choose a file
Order forms, request forms, inquiries etc
Cancel
of
Add Another Test Recipient?:
Yes
No
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Zip Code:
Date of Birth
*
-
Month
-
Day
Year
Date
Reason
*
Please Select
Probation
Pre-employment
Personal
Court Ordered
Other
Random
Post Accident
Reasonable Suspicion
Return to duty
Follow Up
Fit for duty
Reason for Test
Direct Observation Required?:
Only "yes" for probation
Quantity:
*
How do send the results?
*
Email
Fax
Email & Fax
Enter Valid Email:
*
Where should the test results be emailed?
Please include and additional info:
File Upload:
Browse Files
Drag and drop files here
Choose a file
Order forms, request forms, inquiries etc
Cancel
of
Add Another Test Recipient?:
Yes
No
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Zip Code:
Date of Birth
*
-
Month
-
Day
Year
Date
Reason
*
Please Select
Probation
Pre-employment
Personal
Court Ordered
Other
Random
Post Accident
Reasonable Suspicion
Return to duty
Follow Up
Fit for duty
Reason for Test
Direct Observation Required?:
Only "yes" for probation
Quantity:
*
How do send the results?
*
Email
Fax
Email & Fax
Enter Valid Email:
*
Where should the test results be emailed?
Please include and additional info:
File Upload:
Browse Files
Drag and drop files here
Choose a file
Order forms, request forms, inquiries etc
Cancel
of
Add Another Test Recipient?:
Yes
No
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Zip Code:
Date of Birth
*
-
Month
-
Day
Year
Date
Reason
*
Please Select
Probation
Pre-employment
Personal
Court Ordered
Other
Random
Post Accident
Reasonable Suspicion
Return to duty
Follow Up
Fit for duty
Reason for Test
Direct Observation Required?:
Only "yes" for probation
Quantity:
*
How do send the results?
*
Email
Fax
Email & Fax
Enter Valid Email:
*
Where should the test results be emailed?
Please include and additional info:
File Upload:
Browse Files
Drag and drop files here
Choose a file
Order forms, request forms, inquiries etc
Cancel
of
*
Any personal health information (PHI) provided is highly confidential. It is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to an individual. Any other use is a violation of Federal Law (HIPAA) and will be reported as such. This e-mail, including attachments, may include confidential and/or proprietary information, and may be used only by the person or entity to which it is addressed. If the reader of this e-mail is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution or copying of this e-mail is prohibited. If you have received this e-mail in error, please notify the sender by replying to this message and delete this e-mail immediately.
5 Panel Drug Test
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5 Panel Drug Test
The 5 panel drug test is the most popular test ordered for employment or for probation. The specific drugs that we test for on the five panel test are: Marijuana Cocaine PCP Amphetamine (including Methamphetamine and MDMA, ‘Ecstasy’) Opiates (including codeine, morphine and heroin)
$
69.00
Quantity
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