CREDIT SCHEDULING CREDIT SCHEDULING FOR WALK-IN CREDIT SCHEDULING FOR WALK-IN Company Name: * Requester's Name * First Name Last Name Requester's phone number: * (###) ### #### DONOR(S) INFORMATION Default zip code for testing? (If more than one, add into donor information next to their name) Donor(s) Name, Phone Number, & D.O.B) zip code if different than above * (One per each line if more than 1 donor) WHAT IS THIS CREDIT FROM? * ON-SITE RESCHEDULING OR REPLACING AN INDIVIDUAL DONOR IF REPLACING DONOR OR RESCHEDULING, WHO WAS THIS CREDIT UNDER? (Name of the original Donor if Applicable) How many credits are you using? * Is the type of test same as the most recent? * YES NO, A DIFFERENT SELECTION iF OTHER, WHAT TYPE OF TEST? METHOD OF TESTING * URINE HAIR BLOOD IS THE EMAIL FOR RESULTS SAME AS MOST RECENT? * YES NO, A DIFFERENT EMAIL Email for results? (If different than previous) ADD ON'S * BODY HAIR COLLECT OBSERVED COLLECTION INSTANT TEST (ONLY FOR 5 OR 10 PANEL) PUT AN EXPIRATION DATE ON TEST NONE OF THESE APPLY If you would like to add an expiration date: Test expiration Date (If you want to add an expiration date to complete test) MM DD YYYY Time of expiration Date (All time zones apply, don't mind the eastern time zone) Hour Minute Second AM PM Once submitted, a member from our team will fulfill your request. A barcode will be generated and sent to your email with the location and donor infromation for a walk-in * I AGREE Thank you!