Drug Testing Referral Form

Drug Testing Referral Form
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Expiration Date:

MonthDayYear
Date client will be coming to office or mobile site
What type of Testing are you requesting?*

Mobile TestingIn-office (IRP Office testing)
Click Here for Drug Testing Explanations
In-Office Testing Options*
Mobile Testing Options*
Optional Tests and Add-ons. These are an additional fee and must have Supervisor approval.

Fentanyl - UrineXylazine - Urine14-Panel Hair includes FentanylHair ETG (90 day Alcohol Summary)14-Panel Nail includes Fentanyl7-Panel Hair: Environmental Exposure (Use vs. Exposure)
Name of Supervisor who Approved Optional Tests and/or Add-ons.
Additional Tests/Comments
Caseworker Info:

Full NameAgency
Caseworker Email:
example@example.com
Caseworker "Signature": Type Name or Initials for Authorization
Should be Empty: