E-Laboratory Request Form; Fax Request Form to 770-376-6557

Name: _____________________________________________________

Address: ___________________________________________________

City: __________________________ State: ___________ Zip: ________

Phone: __________________________ Fax: ______________________

E-mail Address: ______________________________________________


You can schedule a same-day appointments. Appointments must be made 1 hour prior to time of arrival.

COLLECTION TYPE (CHECK ALL THAT APPLY)

[  ] Routine Lab Collection                            [  ] Occupational Urine Drug Screen Collection

[  ] DNA Collection                                        [  ] On-Site Point of Collection Drug Screen

[  ] Employee Wellness                                 [  ] Pharmacogenetic – Drug Reaction Test

[  ] Other Test Request: ______________________________________________

Date of collection requested: ______ / ______ / ______

Time of collection requested: _________  [  ]
A.M.      [  ] P.M.

Additional Comment: __________________________________________________________

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