12 PANEL DRUG SCREENING CONSENT FORM

DISCLAIMER

By completion and submission of this form, I hereby authorize without reservation 24/7 Drug & Alcohol Testing Center and their representative agents, and Company/School noted above to receive any background check results and/or  drug screeing test results pertaining to me.  I grant 24/7 Drug & Alcohol Testing Center permission to perform a drug screening test using the information I have provided them.

I release Client Company and 24/7 Drug & Alcohol Testing Center their respective employees, agents, and all persons, agencies and entities providing information or reports about me from any and all liability arising out to the release of any such information.  I understand that if I am under the age of 18, I must have my parent, or my legal guardian grant their permission for the background check and drug screening test  to be performed.

The information provided above will be used solely for the service intended and will be kept in confidence. All background information will be forwarded to the authorized personnel for completion of pre-employment  or clinical rotation application. If you have any questions or need any additional information please feel free to contact our office or email us at 247DAT@GMAIL.COM

Name(required)

CURRENT ADDRESS (INCLUDE CITY, STATE & ZIP)(required)

Email(required)

Date of Birth (MM/DD/YYYY) (YYYY-MM-DD)(required)

Phone(required)

Name of school(required)

Comment

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I agree to the disclaimer.

Submit

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12 Panel Drug Screen

$65.00