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Van Buren County Specialty Courts
Drug Testing Referral
Client's Name
First Name
Last Name
Client's Date of Birth:
-
Month
-
Day
Year
Date
Client's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Court:
Judge:
Referring Individual:
Referrer's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer's Email
example@example.com
Referrer's Fax
One time only drug testing?
Yes
No
Random Drug Testing?
Yes
No
How Often
Please Select
1
2
3
4
5
number of times
How Often
Please Select
Per Week
Per Month
week or month
Date ordered to appear by:
-
Month
-
Day
Year
Date
Date testing should conclude:
-
Month
-
Day
Year
Date
Any allowed prescriptions?
Type of Test:
PBT:$2.00
Standard 15 panel instant test: $25.00
Oral Only: $20.00
If more than one type test needed advise below:
Billing option:
Invoice referring court
Client self-pay
If client is paying payment must be made at the time of testing.
All results and no-show reports will be mailed to referring party.
One month of no shows will result in the client’s case being administratively closed, with no further reports.
The providing of the specimen is observed by Van Buren County personnel.
The Drug Testing Coordinator’s direct telephone number is (269) 657-8200 ext. 2478
Submission
Would you to receive an email copy of this form?
Yes
No
Email
This field is not a part of the form Submission
Please verify that you are human
*
Signature
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