Drug Testing Order Form
Business & Volume Pricing Available — Call (817) 865-7990 or Email info@testwiselabs.com
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
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-
prev
next
( X )
DOT Drug Test
DOT Drug Test- Includes MRO Review
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Rapid Oral Drug Test
Rapid Oral Drug Test- Results in 4 Minutes
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
OnSite Fee
Flat Fee- Covers travel up to 25 miles from 76063. Testing for up to 10 individuals. Over 25 miles $1.50/mile. For more then 10 individuals please contact for a personalized quote.
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
After Hours/Weekend Fee
For testing done between the hours of 7pm-8am and weekends
$
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: