Hair Drug Test 5 Panel

Hair Drug Test 5 Panel – Cocaine, marijuana, opiates (Codeine, Morphine & 6-MAM Heroin Metabolite), amphetamines (Methamphetamine & Ecstasy), and phencyclidine (PCP). Hair is cut from the head or from the arms or legs if you don’t have enough hair on your head. (Up to 90 day Look back)

Price: $159.00(each)

Quantity of Tests
Multiple Recipients

#1 Test Recipient

Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
Direct Observed Required?
Does the Test Collection need to be directly observed?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#2 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
Direct Observed Required?
Does the Test Collection need to be directly observed?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#3 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
Direct Observed Required?
Does the Test Collection need to be directly observed?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#4 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
SSN*
For specimen ID tracking purposes. Employee ID accepted. Minimum 6 Digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#5 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#6 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#7 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#8 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#9 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue
#10 Test Recipient
Name*
First Last
Phone*
Email (To Receive Test Pass)*

The test registration order will be sent here.
Zip*
The tests be performed near this zip code.
Date of Birth*
MM slash DD slash YYYY
Reason*
What is the reason for the test?
DOT Agency*
Donor ID*
Example: SSN, Employee ID, Phone number or unique ID of at least 6 digits
CDL Number*
For FMCSA drivers, enter CDL number and state of issue.
State of Issue

How will we send the results?
Where should the test results be emailed?*
Where should the test results be faxed?*
Who should we attention the fax to?*
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Product Name
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Total

Hair Drug Test 5 Panel

Price: $159.00(each)

#1 Test Recipient

#2 Test Recipient

#3 Test Recipient

#4 Test Recipient

#5 Test Recipient

#6 Test Recipient

#7 Test Recipient

#8 Test Recipient

#9 Test Recipient

#10 Test Recipient