ClearPath Mobile Collection Request

ClearPath Mobile Collection Request

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Full Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
E-mail
example@example.com
Phone Number
This is my:
Emergency Contact

First NameLast Name
Phone Number
3. Type of Test
OPTION #_____
6. Preferred Date and Time
ClearPath Collections- Client Policies

By submitting this request, you agree to the following:

All collections are performed by trained professionals in accordance with testing guidelines.
Clients must provide a valid government-issued photo ID at the time of collection.
Missed appointments or last-minute cancellations may result in a rescheduling fee.
Results and documentation are handled securely and shared only with authorized recipients.
Turnaround times vary by test type and lab; most results are returned within 1–5 business days.

Client Agreement & Authorization:

I certify that the information provided is accurate to the best of my knowledge. I authorize ClearPath Collections to conduct the selected testing services and to release results to me or my authorized representative, as applicable. I understand and agree to the policies listed above.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature

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Date

MonthDayYear
Date
Upload Photo ID

Cancelof
Documents

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