Please complete all fiels marked with an aterisk.

Select Your Service*

Select preferred appointment time windows

Morning (8:00 AM - 11:00 AM)Midday (11:00 AM - 2:00 PM)Afternoon (2:00 PM -4:00 PM)Evening (4:00 PM - 7:00 PM) Availability request (additional fee may apply)Saturday Morning (8:00 AM - 2:00 PM) Availability request (additional fee may apply)

Preferred Days

*Evening and weekend appointments are subject to collector availability and may require an additional fee. If selected, we will contact you to confirm availability and pricing before scheduling.

Do you need Mobile Collection? (additional fee may apply)*

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Payment & Scheduling Policy

I understand that submission of this form does not confirm an appointment. An invoice will be emailed for coordination and testing services. Scheduling will only occur after payment has been received and verified. I acknowledge that appointment availability is not guaranteed until confirmation is provided by Great Expansion Enterprise LLC.

Consent for Coordination, Collection & Results Authorization

I voluntarily request coordination services through Great Expansion Enterprise LLC and understand that the company operates as a third-party administrator that coordinates testing services but does not perform laboratory testing or medical diagnosis. I consent to the collection and testing of my specimen(s) by certified collection providers and independent laboratories in accordance with applicable laws and program requirements. I authorize the release of my test results to the authorized recipient(s) listed within this form and acknowledge that results will not be released to any other party without proper authorization or legal requirement.

Electronic Communication & Secure Results Delivery Consent*

I consent to receive appointment communications, testing updates, and test results electronically through email, text message, or secure electronic delivery. I understand these communications may include protected health information (PHI) and that standard email may not be encrypted unless otherwise requested. I acknowledge that Great Expansion Enterprise LLC will deliver results only to authorized recipients and that electronic access to results may be time-limited for security purposes.

Signature*

Authorized Representative Full Name

First NameLast Name

Title*

Today's Date*

Date

Drug Screen Client Information Form

Client Information

Authorized Results Recipient