TPA Phone #: *

(###)

###

####

Date of service *

MM

DD

YYYY

Time of service *

Hour

Minute

Second

AM PM

Select the following *

On-site

Walk-In

Select the following *

Collection Only (You will use your lab & Material)

Full Service (we will use our lab and supplies)

Type of test *

(select all that applies)

5 Panel (standard) (urine)

5 Panel rapid (urine)

5 Panel DOT

5 Panel (Mirror DOT panel) not regulated by DOT

5 Panel Har

10 Panel (standard) (urine)

10 Panel Rapid (urine)

monitored test ($20 additional to test

Breath alcohol

Standard urine (8-hour lookback)

ETG (80-hour lookback)

other

Reason for test *

Pre-employment

Random

Reasonable Suspicion

Post Accident

other

ONSITE CONTACT PERSON *

First Name

Last Name

# Phone Number (on-site contact) *

(###)

###

####

Address for on-site location *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I agree to terms & conditions *

Yes

Upon the on-site taking place, a payment must be made upfront unless an account was established for invoicing. *

I Agree