R&S E-Drug Request Form
Please call (386) 562-1052 for assistance. Thank You
Request Date
Company Name
Business Account Number
7
Ordering Provider/Officer
PATIENT/CLIENT INFORMATION
Patient/Client Name
D.O.B
Phone Number
Purpose of testing
Pre-Employment
Random Drug Testing
Student Enrolment
Post-Accident
Return-To-Duty
Follow-Up
Select Test
5 Panel Drug Test (Urine)
10 Panel Drug Test (Urine)
12 Panel Drug Test (Urine)
14 Panel Drug Test (Urine)
Alcohol Test (Urine)
Marijuana Test (Urine)
Alcohol Breath Test
Submit Request
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