Company/Entity

Type of Test*

Company/Entity (Manual Entry)

Complete if not in Dropdown List

Name*

First Name Last Name

Phone Number*

Location of Test*

Email

example@example.com

Date*

Date Hour Minutes AM/PM Option

Reason For Test*

Exp. Date*

Observed*

Temperature*

Lot # of Screening Device*

Cocaine

Amphetamines

Methamphetamines

THC

Opiates

Benzodiazepine

Barbiturates

Methadone

Oxycodone

Propoxyphene

Collector*

I certify that I provided my unadulterated specimen to the collector & understand
that the specimen was used for drug analysis by San Quest, LLC
dba Accurate Diagnostic & the results of the analysis will be released to
the above-named entity. I hereby release San Quest, LLC, their employees,& contractors
from any liability arising from the release of the results.

Signature

Clear