10 Panel Drug and Breath Alcohol

$132.00

Substances Tested	6-Amphetamine, 6M-AM (Heroin), Alcohol, Amphetamine, Barbiturates, Benzodiazepine, Cocaine, Marijuana, Methadone, Methamphetamine, Morphine, Opiates, Phencyclidine (PCP), Propoxyphene

Breath Alcohol Test – Non DOT and non DOT 10 Panel Drug Test

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Test Ordered

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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)

Date of Birth(Required)

Last 6 of SSN(Required)

(For specimen tracking purposes) FOR FMCSA, PROVIDE CDL NUMBER AND STATE OF ISSUANCE.

Reason for Test(Required)

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.

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, 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?(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

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How should we send the results?(Required)

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Email address to send results(Required)

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Fax number to send results(Required)

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Who should we attention the fax to?(Required)

Test Requisition

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Please send the test requisition form to:(Required)

Donor

Someone else

Following Persons will Receive Test Requisition

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

Email address(Required)

Direct Observation Fee

Price:

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