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
2 digit month, 2 digit day, 4 digit yearDate
TIME REQUIRED FOR DATE OF SERVICE
Is this for DOT or NON DOT testing?
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?
Preferred Specimen Type

Other
Preferred Testing Method
What type(s) of testing do you need?
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: