Drug Testing Order Form
1. Please fill out this form if you need to schedule drug testing for 1 to 5 donors. 2. You can use this form for same-day or future appointments. Once submitted, a member of our team will confirm your appointment details shortly. 3.If testing is needed between the hours of midnight-8:00 am call or text 817-865-7990 to schedule to ensure a collector is available.
Company Name:
*
Company Representative"
First
Last
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Test Type Request:
*
Please Select
Rapid 12 Panel Test
DOT Test
Group Home/Halfway House Test
Oral (5 Panel)Test
Test Frequency:
Please Select
Once
Daily
Weekly
Bi-Weekly
On Call
Monthly
Address Where Test Will Be Preformed:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment
*
Drug Testing Standard Fees-
*
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Rapid Oral Drug Test-6 Panel
Rapid Oral Drug Test-6 PANEL- Results in 4 Minutes. NON DOT - examples are warehouse employees, employment agencies, medical, education, probation, halfway house etc.
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
DOT 5 Panel Drug Test
DOT Drug Test- Includes MRO Review. Results in 2-5 days. We do post accident, return to duty, randoms, reasonable suspicious, new hires, Results will be available online via personal portal.
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Rapid 13 Panel Drug Test
Rapid Test- 13 Panel (tests for 13 different substances including alcohol) Test results in 4 minutes. Good for employment agencies, drug counselors, new hires, students etc.
$
80.00
Quantity
1
2
3
4
5
6
7
8
9
10
OnSite Fee
Required for travel over 10 miles from Mansfield TX and or/ 2 Donors and more
$
30.00
Quantity
1
2
3
4
5
6
7
8
9
10
After Hours/Weekend Fee
For any testing performed AFTER 8PM Weekdays and from Fridays at 6pm until Mondays 8:00am
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
PROMO CODE
Donors Name
*
First Name
Last Name
Donors Name
First Name
Last Name
Donors Name
First Name
Last Name
Donors Name
First Name
Last Name
Donors Name
First Name
Last Name
Continue
Continue
Signature
Should be Empty: