Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Appointment
📜 Service Agreement & Consent “I acknowledge that I am voluntarily requesting testing services from Shiloh Screenings LLC. I understand that all results are confidential and will be released only to authorized parties. I agree to comply with testing policies and understand that no refunds will be given once testing is completed.”
*
Yes
HIPAA Compliance Acknowledgment“I understand that my personal health information will be protected under HIPAA laws and will not be shared without my consent unless required by law.”
*
Yes
Signature
Submit
Submit
Shiloh Screenings LLC
Mobile Drug and DNA Testing Services
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