DONOR ORDER FORM REPRESENTATIVE TAKING ORDER * (Precision Mobile Testing Representative) Has this customer tested with us previously? * (If yes, they may want to order replica test and location) New Customer New Company/Employer Returning Customer Returning Company Unknown Are you scheduling Multiple donors? * NO YES I AM SCHEDULING MULTIPLE DONORS Default Panel Code (If applicable) Default Location (If applicable) Customer Description * INDIVIDUAL THIS IS AN EMPLOYER OR ESTABLISHMENT OTHER Employer/Company Name (If applicable) Donor Name * Person providing specimen First Name Last Name Date of Birth * MM DD YYYY Donor Phone Number * (###) ### #### SS# (optional) Zip code for testing * Reason for testing? * Pre Employment Random Probation Court Order Post Accident Reasonable suspicion Follow up Other Other (If Applicable) Email for Barcode authorization * Email for results * Do the results need to be faxed? * (Or add additional email) NO FAX OVER RESULTS SEND TO ADDITIONAL EMAIL Fax # (Or additional Email) DOT or NON-DOT? * NON-DOT DOT (Department of Transportation) ............. This section is for DOT ............. If DOT what mode? FMCSA USCG FRA FTA PHMSA For DOT (FMCSA) what is CDL licence# & state, All other modes: full social DOT (COMPANY NAME) DOT (DER) (Designated Employee Representative) DER (PHONE NUMBER) (###) ### #### USCG ONLY (WHICH OF THE FOLLOWING ARE NEEDED?) (If a physical is needed schedule at Concentra and/or contact a facility that can fill out the following forms) NONE PHYSICAL 719K FORM (CAPTAIN APPLICATION FOR MERCHANT MARINER MEDICAL CERTIFICATE) PHYSICAL 719KE FORM (ENTRY LEVEL APPLICATION FOR MERCHANT MARINER MEDICAL CERTIFICATE) 719P FORM (PRE-EMPLOYMENT TESTING used to document your required Coast Guard drug test) ............. DOT SECTION STOPS HERE ............. Type of Test/Panel * 4 Panel (NO THC) 5 Panel DOT 5 Panel 5 Panel Rapid 5 Panel + Expanded opiates 10 Panel 10 Panel Rapid 10 Panel + expanded opiates (considered our 12 panel) BAT ALC (STANDARD) ETG Other If other, what Panel do you need? Method * Urine Hair Blood Neither Applies ANY ADD ONS? * (ADD THE ADDITIONAL FEE) Body Hair (confirmed at least 1 & 1/2 to 2 inches of hair) (add $20) Observed Urine collection (add $20) NEITHER APPLIES INDIVIDUAL RANDOM ENROLLMENT $49 TOTAL TEST COST: * include any add Ons the customer selects $ Is this a partial plan? * NO THIS IS A PORTION OF THE COST This Section is for Partial payment only Partial Payment Amount (If partial Payment, what is the amount being paid?) $ Total amount Due? $ Partial Payment Ends here Name on cc CC# Exp Date Security code CC Zip code DID YOU READ THE REFUND POLICY? * YES NO LAB SCHEDULED? * QUEST - PORTAL LABCORP - PORTAL I3 SCREEN - PORTAL I SCHEDULED ON INTELLESHIELD/INSTASCREEN THIRD PARTY SCHEDULING I AM ON TRAINING MODE Are you applying an exisiting credit? Make sure you verify the credit is accurate and exists Yes No If so, how many credits remaining? is this a prepaid order? * (Fill out information below if yes) NO YES, I PURCHASED MULTIPLE TESTS UPFRONT Number of prepaid orders Number of prepaid tests scheduled Number or prepaid tests left? Make sure to schedule the test in the desired portal * Scheduled Working on it after I submit Additional Notes/ information Be sure to schedule the donor in the desired portal after submission!