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DRUG/ALCOHOL SCREENING
AUTHORIZATION FOR EXAMINATION

(Patient must present photo ID at each time of service)

Download printable form here


REFERRAL DATE

PATIENT INFORMATION
Client Name:
Last
First
M.I.
  
Race: Gender:         
Date of Birth: SSN:   
last four digits only
  
Phone Number:    ()- Cell Number:     ( ) -  

Drivers

License #:

 Issuing State    :  
Client Address:
Street Number and Name
City
State              Zip
 
 
  

COURT INFORMATION (If applicable)
Judge: Court:      
Docket#: /      
Referring Person:

,

Last name                                     First name
 Phone Number:     ( )-
Agency: Fax Number:           ()-

TESTING REQUEST
TEST

5 Panel DrugTest

10 Panel Drug Test

No Drug Test

Alcohol:      Yes No Other:  

Frequency of Drug Testing(s) :

Please fill in # of days/week/month and indicate whether testing should be performed on weekends and holidays also.
     Weekends Yes No
Holidays    Yes No
Frequency of Alcohol (PBT) Testing :    

Weekends Yes No
Holidays     Yes No
Frequency of Other Testing :    

Weekends Yes No
Holidays     Yes No
Testing is to begin on:    Testing is to end on: N/A   

PATIENT RELEASE
I,                                                           authorize Precision Testing Laboratories to release all test results to the above court/agency/individual(s). I understand that the cost of the testing will be paid by me before services are provided by Precision Testing Laboratories. If a non-negative test result occurs, I will be given the opportunity to have the results re-checked/confirmed at my cost. Failure by myself to pay for submission of a non-negative sample for laboratory testing is considered confirmation of the results. A picture ID is required before testing will be done.
      

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