Name *

First Name

Last Name

Phone

(###)

###

####

Do you anticipate needing collection services?

*We do not offer on-site collection services but have access to nationwide collection centers

Yes

No

Is this DOT regulated testing?

Yes

No

Unsure

What is your anticipated approximate monthly test volume?

Individual (single test only)

1-5

6-10

10-20

20-50

50+

Please select the type(s) of testing you are interested in from the menu shown below.

We are more than happy to build custom panels and offer additional tests beyond the scope of what is shown below.

Standard Urine Drug Screen

Alco Screen (Oral Fluid)

Rapid Urine Screen (done at collection facility; presumptive positives sent to lab for confirmation)

Oral Fluid

Hair Testing

Custom Panel Not Listed

Do you wish for MRO review of services performed elsewhere?

Yes, I'd like review of positive tests results with donor evaluation and secure test reporting

Yes, I'd like review of all test results before release to client

How do you wish to register donors?

Online registration

Paper chain of custody forms

How do you wish to receive results?

*regular email is not considered secure

Secure online transmission

Fax

US Mail