THIRD PARTY INFO Use this form to log in information from a third party collection site Third Party info Form Representative name: * (Your name) Company or client inquiring about these services * (Include detailed notes) Zip code: * (TPA) Company Name: * Who did you speak to (TPA) ? * (TPA) City and State: * (TPA) full address: (TPA) Phone #: * (TPA) Email * Can the TPA invoice us? * Yes they can invoice us Up front payment over the phone Other (include detailed note) Select which one applies * Collection Only (using our lab) Full Service (using TPA's lab) Urine collection fee: $ Hair Collection fee: $ On-Site fee (if this is on-site what is the fee) $ Select the following Per Hour Per Mile Flat rate Other (Please detail in notes) After Hours/Additional Fees: (If applicable) $ Select the following Per Hour Per Mile Flat Rate Other (Please detail in notes) Breath Alcohol Fee: (If applicable) $ Select all that apply On-Site 24 hours Walk-In 24 hours After hours (late but not 24 hours) No late or after hours Total TPA Estimate $ Hours of operation (detail the hours of operation) Services they offer Collection only Full service Hair collect Urine collect Breath Alc Non-DOT DOT Precision Pricing Quote * (Our pricing for client) Test Fee, On-site fee ETC. Additonal Details: (protocol) Thank you!