Internal Order Form

Scheduling System*
- MRO
- Alere
- DSI
- Third Party
- Background Check
- MVR
- DNA
- Other
BGC Level*
Collection Fee*
State Fees
LAB*
Specimen ID/Case Number*
Tracking
DOT / Non DOT
- Non - DOT
- FAA
- FMCSA
- FRA
- FTA
- PHMSA
- USCG
Test Purpose
- Pre Employment
- Random
- Post Accident
- Reasonable Suspicion
- Other
5 Panels
- 5 Panel Instant
- 5 Panel
- 5 Panel DOT LIKE -N
- 5 Panel + ETG
- 5 Panel + Alcohol
- 5 Panel DOT
- 5 Panel + Exp Opiates
- 5 Panel + Nicotine
- 5 Panel + Exp Opiates + Alcohol
- 5 Panel Florida Drug Free
10 Panels
- 10 Panel
- 10 Panel Instant
- 10 Panel DOT LIKE - N
- 10 Panel + Alcohol
- 10 Panel + Exp Opiates
- 10 Panel + BUP
- 10 Panel Florida Drug Free
- 10 Panel + Exp Opiates + MDMA
- 10 Panel + Exp Opiates + BUP
- 10 Panel + ETG
- 10 Panel DOT Like + MEP + TRAM
- 10 Panel + Exp Opiates + MEP + FEN
- 10 Panel + Exp Opiates + MDMA + ETG
- 10 Panel DOT Like + Exp OPI + OXY + MEP + TRAM + FENT
Hair Tests
- 5 Panel
- 5 Panel + Exp Opiates + OXY
- 9 Panel
- 12 Panel
- 14 Panel
- 17 Panel
- ETG Hair
- Body Hair Collection
Blood & Misc.
- Occupational Health Service
- Blood Alcohol
- 5 Panel + Alcohol
- 5 Panel + Exp Opiates + OXY
- 7 Panel
- Alcohol Alone
- Physicals
- ETG
- Breath Alcohol
- DOT Compliance Package
- Drug Policy
- Background Check
- MVR
- Consortium Enrollment/Renewal
- Observed Collection
Occupational Health Services*
Background*
Date of Birth*
Date Format: MM slash DD slash YYYY
Shipping/Overnight
Amount / Total
Payment*
- Invoice
- Paid
- Online Order
- Pre Paid
Total Test Pre-Paid*
Number of Pre Paid Tests Remaining*
Pre-paid notes*
Company Name*

Payment Information*

Credit card number	Exp date	Cardholder Name	CVV	Billing zip code

Donor Info

Name	SS#	Phone	Zip

Donor Email / Results Email

Donor Pass Email	Results Email

Notes
Post Custom Field
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Accepted file types: pdf.