5 Panel Instant Urine

$79.00

Panel	5 Panel
OrderSystem	Escreen123, i3, MyEscreen
LABCODE	L10598794 QERO6A A3121

Hidden

Test Ordered

Hidden

Test Name(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)

Email(Required)

Date of Birth(Required)

Test Center(Required)

InOut Labs, Morton Grove, IL

A Testing Center close to an address

Reason for Test(Required)

Does this test need to be directly observed?

Yes

Choose One(Required)

Male Observer

Female Observer

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

Address(Required)

Will be used to locate the closest testing location.

Street Address Address Line 2 City State ZIP Code

Other Reason for Test

Last 6 of SSN(Required)

(For specimen tracking purposes)

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?(Required)

Yes

Results Delivery & Test Requisition

How should we send the results?(Required)

Email address to send results(Required)

Fax number to send results(Required)

Who should we attention the fax to?(Required)

Please send the Test Requisition Form to:(Required)

Person ordering the test

Donor, with a copy to person ordering the test

Product Name

Price:

Total

Subtotal
Extra
Total