REQUISITION ORDER for RESIDENTIAL & SOBER LIVING URINE DRUG TESTING

VITAL REFERENCE LAB

REQUISITION ORDER for RESIDENTIAL & SOBER LIVING URINE DRUG TESTING
Facility Information
Facility name
Facility address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Facility contact person

First NameLast Name
Facility email
example@example.com
Facility telephone
Please enter a valid phone number.Format: (000) 000-0000.
Facility fax number
Resident Information
Resident full legal name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Specimen Collection
Collection date and time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Collector’s full name

First NameLast Name
Laboratory Testing Requested
Presumptive findings from facility cup screen

Other
Testing requested
Facility Authorization
Authorized facility representative

First NameLast Name
Facility representative signature
Facility authorization date and time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Prepayment
Payment method
Date payment made

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Resident Consent and Disclosure Authorization
Facility name for results disclosure
Resident printed name

First NameMiddle NameLast Name
Resident signature
Resident authorization date and time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty:

VITAL REFERENCE LAB