DRUG SCREEN REQUEST

DRUG SCREEN REQUEST
Your Full Name

First NameLast Name
Best number to contact you
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address
example@example.com
Last 4 digits of your social
Your Zip Code
Your Zip Code
Date Test is to be taken

MonthDayYear
2 digit month, 2 digit day, 4 digit year
READ CAREFULLY! You will be contacted to schedule your appointment by a SureScreen Labs Representative. You MUST bring your Registration Number on or before the scheduled test date in order to be tested. You MUST also have a PICTURE ID with you. Have you
You Have Read & Agree to the Requirements Above
Message (If Any)
Who is your PTI or AEP Case Manager?
Should be Empty: