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2. Client's Name:
3. Client's Date of Birth:
   Client's Date of Birth:
4. Client's Phone #:
6. Referring Court:
7. Judge:
9. Referring Individual:
10. Referrer's Phone #:
11. Referrer's Email:
12. Referrer's Fax#:
14. One time only drug testing?

    1. Yes
    2. No
15. Random Drug Testing?

    1. Yes
    2. No
16. How Often
    -- Select One --1234

    number of times

17. How Often
    -- Select One --per weekper month

    week or month

19. Date ordered to appear by:
    Date ordered to appear by:
20. Date testing should conclude:
    Date testing should conclude:
21. Any allowed prescription?
23. Type of Test:

    1. PBT:$2.00
    2. Standard 9 panel instant test:$10.00
    3. Oral Only: $15.00
    4. Lab confirm if positive test and client denies:$30.00
    5. Drivers License Restoration:$120.00
24. Billing option:

    1. Invoice referring court
    2. Client self-pay
26. If more than one type test needed advise below:
28. Please Note:
    1. If client is paying payment must be made at the time of testing.
    2. All results and no-show reports will be mailed to referring party.
    3. One month of no shows will result in the client’s case being administratively closed, with no further reports.
    4. The providing of the specimen is observed by Van Buren County personnel.
    5. The Drug Testing Coordinator’s direct telephone number is (269) 657-8200 ext. 2478 – Asiah Gardner.
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

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