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:
Address Where Test Will Be Preformed:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment*
Drug Testing Standard Fees- *
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Rapid Oral Drug Test-5 Panel
Rapid Oral Drug Test-5 PANEL- Results in 4 Minutes. NON DOT - examples are warehouse employees, employment agencies, medical, education, probation, halfway house etc.

$60.00 Quantity



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.

$75.00 Quantity



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.

$65.00 Quantity



OnSite Fee
Required for travel over 10 miles from Mansfield TX and or/ 2 Donors and more

$30.00 Quantity



After Hours/Weekend Fee
For any testing performed AFTER 8PM Weekdays and from Fridays at 6pm until Mondays 8:00am

$125.00 Quantity



Total

$0.00
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 Order Form