Drug Testing Request Form
Please fill out this form to request a drug test. All information provided will be kept confidential.
Appointment
Requester's Name
*
First Name
Last Name
Requester's Position
*
Requester's Email
*
example@example.com
Requester's Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Employee's Name
First Name
Last Name
Employee's Position
Phone Number
Please enter a valid phone number.
Reason for Test
*
Pre-Employment
Post-Accident
Random
Reasonable Suspicion
Follow Up
Return to Duty
Other
Type of Drug Test
*
Instant Urine Test
Hair Follicle Test
Saliva Test
DOT BREATH
DOT URINE
Urine Lab
DETOX Direct Transport*
Consent and Agreement
Please read below and check the box below
Submit
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