DRUG TEST

DRUG TEST
NAME
DATE OF BIRTH

MonthDayYear
Date
Please list any medications, painkillers or other over - the - counter products you may have taken within the past 2 weeks:
1
2
3
4
Have you taken any medications or painkillers within the last 2 weeks:

YesNo
I hereby give my consent for the drug test to be performed:

YesNo
I hereby give my consent that the result of the drug test is sent to my employer:

YesNo
SIGNATURE
DATE

MonthDayYear
Date
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