Urine Drug Screen Information Form

Urine Drug Screen Information Form

Please complete all required fields and upload your ID to proceed with your drug screening appointment.

Payment for Drug Screening Service

DOT 5-Panel Drug Screening

5-panel federal drug screen.

$65.00

Expanded 10-Panel Drug Screening

Expanded 10-panel urine drug sscreen including additional substances.

$95.00

Non-DOT 5-Panel

Basic 5-panel urine drug screen

$65.00 Quantity

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Federal Testing Authority
If Other, please specify the testing authority
Reason for Test

Other
Observed Collection
Upload Driver’s License or State ID

Cancelof
Signature
Should be Empty: