AccuGen Diagnostics LLC Drug Screen Consent Form

🚨 Eligibility Notice

Must be 18 years or older to complete this form. If the individual being tested is under 18, a parent or legal guardian must complete and sign the form on their behalf.

Tested Party First name

Tested party last name

Tested party phone number

Tested party email

Tested party date of birth

Month

Day

Year

Employer/Organization Name "NA"

Employer address "NA"

Employer fax or email address * if it doesn't apply enter "NA"

DER name (DOT) "NA"

DER fax or email where results will be sent "NA"

Desired Date and Time of Appointment

Month

Day

Year

Time

HoursMinutes

Test Type

Reason for Test

If Other

Upload your government ID

I consent to provide a specimen for drug and/or alcohol testing conducted by AccuGen Diagnostics LLC. I understand that:

My results may be shared with the authorized requesting party.
Refusal to test may result in consequences determined by that requesting party.
Specimen handling will follow industry and legal standards.
I release AccuGen Diagnostics LLC and its staff from liability related to this testing process.

Signature

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Date

Month

Day

Year