Officer Information

First Name

Last Name

Phone

(###)

###

####

Fax

(###)

###

####

Client Information *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Client Phone

(###)

###

####

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Testing Requested

Urine - Instant

Urine - Lab Confirmation

Oral Fluid Test

Alcohol Test (Breath/ETG/Other

Reason for Testing

Random

Scheduled/Routine

Post-Accident

Reasonable Suspicion

Return-to-Duty/Follow Up

Preferred Reporting Method

Email PDF Summary

Fax