Drug Screening Referral (DHS)

Hours are Monday thru Friday 9am thru 8pm, Saturday-Sunday 9:00am thru 5:00pm. closed for Lunch from 12 to 1.
 
Client Name: Court Case # (JD, CM, CF)
Client Phone: (DHS, CW Only), KK#:
Referring Agency:    
Referral Name: Phone:  
Email: DOB:  
Gender: Insurance:
   
Drug Screening Program Options: (Check all that apply)
One Time Test:  or   Random Testing:  ( 7-days (M-Sun) a week)
Random Schedule will consist of .. tests per month for month(s)  OR   tests per week for  month(s)
Type of Testing: (Check all that apply)
          Urinalysis:              
                       1 Panel Drug Requested:  
  8 Panel, (Same Day Results)- Alcohol, THC, Cocaine, Amphetamine, Opiates, Methamphetamine, Benzodiazepines, & Barbiturates
  8 Panel, (Results in 1-3 Days)- Alcohol, THC, Cocaine, Amphetamine, Opiates, Methamphetamine, Benzodiazepines, & Barbiturates
19 Panel, (Results in 1-3 Days)- EtG (Alcohol), THC, Cocaine, Amphetamine, Opiates, Methamphetamine, Benzodiazepines, Barbiturates, PCP, Heroin, Dihydrocodeine, Oxycodone, Buprenorphine, Morphine, Bath Salts, Synthetic Marijuana, Fentanyl, Methadone, TCA's (Antidepressants)
          Adulteration Testing: (Check here, if you think the client is tampering or masking their samples)
            (Additional fees apply. Detects the use of masking agents, bleach, and other methods clients try to use to cover up or hide their drug use)
          Hair Follicle: (Results in 5-7 Days)- 5-panel - Cocaine, Amphetamines, Opiates, THC & PCP).  Can detect regular drug use over 90 day period
          Hair Follicle: (Results in 5-7 Days)- 10-panel - Cocaine, Amphetamines, Opiates, THC , Barbiturates, Benzodiazepines, Methadone, Oxycodone, Propoxyphene & PCP).  Can detect regular drug use over 90 day period
          EtG- Extended Alcohol Urine Test    


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