ONSITE Drug Testing Collection Request Form

ONSITE Drug Testing Collection Request Form

Please provide your company's details and testing preferences to proceed! Will look forward to servicing you!
Company Name*
Company Primary Address *
Testing Site Address (If primary address is the same as Primary Address type SAME)*
Industry of Your Company*
Point of Contact / DER Representative Name*

First NameLast Name
Point of Contact Email Address*
example@example.com
Point of Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
DATE OF SERVICE REQUEST*

MonthDayYear
Date
TIME REQUIRED FOR DATE OF SERVICE*
DOTNON DOT
What drug testing panel is needed?*
If custom panel, please specify the drugs to be tested:
Are Designated Test Area where test will be performed Single- Private Restroom or Multi Stall? *
UrineOral FluidHairOther
RapidConfirmatory (Lab-based)Both
Pre-employmentRandomPost-accidentReasonable suspicionReturn to duty / Follow up
Do our Specimen Collectors require special access instructions to enter Job Site?*
Do you have your own Testing Laboratory with MRO services for further review of non negative testing? If not would you like to use our laboratory services which can be included in the testing prices? *
How quickly will you need testing results? Oral and Urine have options available for immediate results. *
Name of DER/ Representative who will be receiving test results and reports*

First NameLast Name
Representative Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Representative Email*
example@example.com
Estimated frequency of testing
Preferred Billing Method *
Additional comments or special requirements
Should be Empty: