Company *
Email Address *
Title
DR
MISS
MR
MRS
MS
First Name *
Last Name *
How To Result Fax/Email *
Name of Donor *
ID Number
Must Test by:
Donor Phone #
Comments
Urine-Same Day
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5-Panel (FDA Cleared)
5-Panel (FDA Cleared)-Observed
10-Panel (FDA Cleared)
10-Panel (FDA Cleared)-Observed
Urine GCMS Lab
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5-Panel Standard
5-Panel Standard Observed
5 Panel w/THC cutoff 20 ng
5-Panel w/THC cutoff 20ng Observed
5 Panel w/Extended Opiates
5 Panel w/Extended Opiates Observed
9 Panel Standard
9 Panel Standard Observed
9 Panel Narcotics (includes Synthetic Opiates)
9 Panel Narcotics (includes Synthetic Opiates) Observed
10 Panel Standard Medical
10 Panel Standard Medical Observed
Oral Fluid
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Oral Fluid Same Day
Oral Fluid Lab GCMS Confirmed
Hair/Nail
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5 Panel Standard (0-90 day) Head Hair
5 Panel Child Exposure
5 Panel Approx. 12 month Body Hair
5 Panel Nail (30 Day History 6 Months Previous)
5 Panel w/Ext. Opiates (0-90 day) Head
5 Panel Child Exposure w/Ext. Opiates
5 Panel w/Ext Opiates 12 month Body
5 Panel Head Hair 6 month History Counts as 2 Test
5 Panel Head Hair 12 month History Counts as 4 Test
5 Panel Head Hair w/Ext Opiates 6 month History
5 Panel Head Hair w/Ext. Opiates 12 month History
10 Panel Standard (0-90 day)
10 Panel Approx. 12 month History
Alcohol
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ETG-Urine (80 Hour)
Saliva
Breath
Blood/DNA
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Paternity (1 AF & 1 Child)
Paternity (Trio AF
M & C)
Pregnancy (HcG)
Cholesterol
Thyroid Panel
Basic Metabolic Profile
Complete Metabolic Profile
Blood Typing (ABO/RH)
Payment *
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Bill To Company
Donor Will Pay
See Company Code Below
Company Code
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