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Urine Drug Test Panels
/ 10 Panel + K2/Spice
10 Panel + K2/Spice
$
129.00
Lab
Alere
Hidden
Test Ordered
Hidden
Test Name
(Required)
Donor Information
Select DOT Agency
(Required)
Select
FMCSA
FAA
USCG
FTA
FAA
PHMSA
CDL number
(Required)
(For specimen tracking purposes)
State of Issuance
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Donor Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Test Center
(Required)
InOut Labs, Morton Grove, IL
A Testing Center close to an address
Reason for Test
(Required)
Pre-employment
Personal
Post Accident
Fit for Duty
Resonable Suspicion
Court Ordered
Return to Duty
Probation
Random
Follow Up
Other
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
No
Results Delivery & Test Requisition
How should we send the results?
(Required)
Email
Fax
Email & Fax
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
10 Panel + K2/Spice quantity
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