Standard Drug Test Request

First name

Last name

Phone

Email

Address

Contact Preference

Phone

Email

Text

Birthday

Month

Day

Year

Reason for drug test:

Court mandated

Pre-employment

Treatment program monitoring

Other

Describe other reason:

Specify the person, employer, or organization authorized to receive your results. Please include full name, phone number, email, and company.

Specify any individual substances or the exact panel requested by your employer or agency.

I authorize my test results and personal information required to be released to the laboratory for processing and reporting.

I consent to the release of my test results to the individual, employer, or organization I have designated.

I consent to be contacted by the clinic/lab regarding my test results, clarification, or follow‑up, including by phone, text, or email.

Please enter any additional information you'd like to include.

Photo ID

Name of person signing and designation (self, POA, legal guardian):

Signature of patient, legal guardian, or POA

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Drug Test Request