JD3 Mobile DNA Services LLC - Drug Testing Request Form

Our Contact: Phone: 850-220-4673

Call to schedule appointment or walk-in hours for MD location: Monday – Friday 7am to 7pm | Saturdays by appointment only.

Texas location is BY APPOINTMENT ONLY.

Maryland Address:

6111A Old Branch Ave |Suite 2 |Temple Hills , MD 20748 | 24/7 Post Accident Testing Available

Texas Address:

5121 Collin McKinney Pkwy | Suite 500 #176 | McKinney, TX 75070 | 24/7 Post Accident Testing Available

A valid form of ID that is not expired is required before the test is administered

Name of Agency Requesting Drug Test*

Name of the DER (designated employer representative)

Phone Number*

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Email

example@example.com

Name of Employee/Donor*

First NameLast Name

Donor SSN or Employee ID Number*

Type of Drug Test*

DOTNon DOT

Drug Test Panel to be performed (For Ex: 5 Panel, 7 Panel etc.)*

Reason for Test*

Pre-employmentPost AccidentRandomOther

Date Available to be drug Tested*

Date

Time Available to be drug Tested*

Agency Requesting*

Method of payment*

Signature*

Today's Date*

Date