Drug Test Intake Form

Form
What Type of Service Are You Requesting

DOT Drug Test (5 panel)Non DOT Drug Test
Date

MonthDayYear
Date
Donor's Name

First NameLast Name
Upload a copy of your government ID
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do you opt-in to text messages from our office?

YesNo
Email
example@example.com
Date of Birth

MonthDayYear
Date
State where ID was issued
ID Number
Is this a court order

YesNo
If this is a court order you must present the court order at the time of testing to ensure compliance.
Name of Person(s)/Agency/Company Requesting Drug Test (if applicable):
example@example.com
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Appointment
By signing below I understand that there are NO REFUNDS!

Payment is due at the time of service. No exceptions, unless written agreement of other arrangements.

I release Williams Collection of all liability as it pertains to testing as we are just a collection site that collects the specimen. We use accredited labs that test the specimen and give the results.

I understand that the results can take up to 5 business days once the lab has recieved the specimen. Please wait the full 5 days before calling for results. If a test is positive it could take longer because the MRO will have to make contact before releasing the results.

I understand that if I have questions that need to be answered by a doctor, specifically the Medical Review Officer (MRO) a 15 min consultation may be requested for an additional $25.
Signature

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What form of ID will you present (not expired)

CDL or Drivers LicenseState Issued IDPassportMilitary IDEmployee Badge
Should be Empty: