Drug Testing Enrollment Form

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"

FirstLast
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Test Type Request:*
Test Frequency:
Mobile (address required)Our Location in Mansfield 287/Broad Street (address will be sent once booked)
Address Where Test Will Be Preformed

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment*
Please note that other fees may be incurred:
* Some examples are shy bladder/no show/etc.
Donors Name*

First NameLast Name
Donors Name

First NameLast Name
Donors Name

First NameLast Name
Donors Name

First NameLast Name
Donors Name

First NameLast Name
Signature

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Drug Testing Standard Fees- *

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.

$70.00 Quantity

Rapid Oral Drug Test-5 Panel

Rapid 5 Panel Oral (Saliva) Drug Test - Results in 4 Minutes. This test is NON DOT.

$50.00 Quantity

Rapid 13 Panel Drug Test

Rapid 13 Panel Drug Test includes testing for Fentanyl & Alcohol - Results in 4 Minutes. This test is NON DOT.

$75.00 Quantity

Mobile On-Site Service (We Come to You)

DFW includes many surrounding cities. Please select the closest service area. Travel fees are based on location and will be confirmed after booking

$ Free

Mobile On-Site Fee	Quantity	Price
In Office or Mansfield		$0.00
Arlington,Fort Worth,Grand Praire, Cedar Hill, Midlothian		$35.00
Duncanville,Dallas (South/Central) Irving,Desoto, Duncanville		$65.00
Plano, Frisco, McKinney, Allen, Richardson, Carrollton		$75.00
Outside of DFW		$100.00

After Hours/Weekend Fee

For any testing performed AFTER 8PM Weekdays and from Fridays at 6pm until Mondays 8:00am

$50.00 Quantity

Total

$0.00

Should be Empty:

Drug Testing Order Form