Drug Test Consent Form

Drug Test Consent Form
I understand that my refusal to provide for urine and/or blood specimen, tampering, or providing false information through the specimen’s chain of custody shall be grounds for termination or non-acceptance of my employment.

I understand that my failure to pass the drug test may result in disciplinary action, pending, termination or non-acceptance of my employment with the Company, or may require me to participate in a rehabilitation program to the discretion of the Company or as provided for in the company policy.

I hereby release, indemnify, and hold harmless the Company, its employees, directors, and its agents from any liability, loss, or expenses, injury, damage, or claims whatsoever on or about this drug test.

I understand that all information disclosed by and acquired by the company as derived from this test shall be kept confidential and shall solely be used for the purpose described herein.
Name

First NameLast Name
Employee Number
Email
example@example.com
I hereby give my consent in providing collection of the following by the laboratory designated by the Company or its agent for the purpose of drug testing. I understand that the results of the test will be sent to the Company's designated medical representative and shall form part of my employment records.
Signature of Undersigned
Signed Date

MonthDayYear
Date
Signature of Witness
Signed Date

MonthDayYear
Date
Should be Empty: