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.

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

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
Consent For Drug Testing

I voluntarily consent to the collection of a specimen and the analysis for drugs/alcohol. I understand that my specimen will follow chain-of-custody procedures and be sent to a certified laboratory. Refusal to provide a specimen or adulteration may result in a positive result. I have the right to request a split specimen for independent testing (if applicable).
HIPAA Authorization For Release of Results

I authorize TestLynx Nationwide to disclose my test results and related PHI to:
Receiving Party Name
Purpose of Release
(e.g., Pre-employment, Legal, Random Testing, Personal Knowledge)
Signature
Consent & Authorization
Should be Empty:

Consent For Drug Testing