DRUG SCREEN REQUEST

DRUG SCREEN REQUEST
Your Full Name*

First NameLast Name
Best number to contact you*
Please enter a valid phone number.
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
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
YesNo
Message (If Any)
Who is your PTI or AEP Case Manager?*
Should be Empty: