5 Panel Oral Fluid

$75.00

Substances Tested	6M-AM (Heroin), Amphetamine, Cocaine, Marijuana (THC), MDMA (Ecstasy), Opiates, Phencyclidine (PCP)
Panel Codes	LA780400, QU40012N

Our 5 Panel Oral Fluid panel tests for the following drugs*:

Marijuana (THC), Cocaine, Amphetamine, MDMA (Ecstasy), Opiates, 6M-AM (Heroin), Phencyclidine (PCP)

*If listed, Amphetamines includes Methamphetamine. Opiates includes Codeine and Morphine. Expanded Opiates includes Hydrocodione and Hydromorphone.

This field is hidden when viewing the form

Test Ordered

This field is hidden when viewing the form

Woo Product Category(Required)

This field is hidden when viewing the form

Test Name(Required)

This field is hidden when viewing the form

Woo Product ID(Required)

This field is hidden when viewing the form

Panel Code(Required)

Donor Information

Select DOT Agency(Required)

CDL number(Required)

(For specimen tracking purposes)

State of Issuance(Required)

Donor Name(Required)

First Last

Phone(Required)

Date of Birth(Required)

Last 6 of SSN/ CDL Number(Required)

FOR FMCSA, PROVIDE CDL NUMBER AND STATE OF ISSUANCE.

Reason for Test(Required)

Direct observation fee will be added to this order
Direct observation means that a same-sex observer goes into the bathroom with the donor for a urine collection. It is a manual process to locate a site with an available observer which may cause a delay in receiving your donor pass.

Does this test need to be directly observed?

Yes

This means that a same-sex observer goes into the bathroom with the donor for a urine collection. It is a manual process to locate a site with an available observer which may cause a delay in receiving your donor pass. THIS OPTION APPLIES ONLY TO URINE TESTS.

Choose One(Required)

Male Observer

Female Observer

Return to Duty and Follow Up Drug Tests are under direct observation as per DOT rules.

Address(Required)

Will be used to locate the closest testing location, or, for Proctored Oral Fluid tests, where the kit will be shipped.

Street Address Address Line 2 City State ZIP Code

Other Reason for Test

Hair Collection
Hair tests are typically cut from the scalp. In cases where enough head hair is not available, body hair (arms, underarms, chest, leg) can often be used. Not all collection sites will collect body hair.

Can Donor Provide Head Hair (min 2 inches)?(Required)

Yes

Results Delivery

Details for Results Delivery

How should we send the results?	Email address to send results	Fax number to send results	Actions

There are no Entries.

You may have results sent to more than one individual.

This field is hidden when viewing the form

How should we send the results?(Required)

This field is hidden when viewing the form

Email address to send results(Required)

This field is hidden when viewing the form

Fax number to send results(Required)

This field is hidden when viewing the form

To whose attention (fax)?(Required)

Test Requisition

The test requisition is the order for the test. If you are ordering for yourself, enter your information. If you are ordering a Proctored Oral Fluid test make sure to provide the Donor's email address, as that is where all of the notifications will go.

This field is hidden when viewing the form

Please send the test requisition form to:(Required)

Donor

Someone else

Following Persons will Receive Test Requisition

Name	Email address	Mobile Number	Actions

There are no Entries.

Test requisition form will be emailed to {Email:4}

Email address(Required)

Direct Observation Fee

Price:

Total

Subtotal
Extra
Total