Name of requestor *

First Name

Last Name

Requester's phone number: *

(###)

###

####

Select the following *

Walk-In

On-site/Mobile Testing

Preferred time if On-site testing

Hour

Minute

Second

AM PM

If this is a group random, please send a spreadsheet of the names *

(Send to compliance@precision-mobiletesting.com or upload file below)

I Understand

Does Not apply to me

Are there any policy specifics our collector should know about? *

No (Collector can do their standard process)

Yes, I have policy specifics (please include below)

Method of testing?

(Hair and blood is not available for on-site testing, only walk-in)

Urine

Hair

Blood

Add ons

Body Hair +($20)

Monitored +($20)

Instant test (Only 5 or 10 panel urine only available for rapid)

Frequency *

(How often are you required to test for during the time of your randoms?)

Daily

Once a Week

Once a month

Once a year

Twice a week

Twice a month

Twice a year

Quarterly

Every other week

Every other month

Other

Effective Date *

MM

DD

YYYY

End Date *

MM

DD

YYYY

Payment for on-sites will be collected up front 48 hour prior to the time of service *

I AGREE

A Payment for the enrollment fee will be taken upfront *

(Nothing is set up or confirmed until a payment is made)

pay for enrollment Now

Pay Later When I am ready to begin the process

I agree to terms and conditions *

I AGREE