Urine Drug Screen
Internal Office Form
Date of Service:
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 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
PROVIDER
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RAYMOND SANCHEZ PA.
PRIYADARSHAN BAJPAYI MD.
BINU CHACKO MD.
TATYANA GOYKHBERG NP.
ALINE RABEL NP.
KERRI QUAIL PA.
SIJI VARGHESE NP.
Urine Drug Screen Result: (Check all that apply)
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Positive Bupenorphine
Positive Opiates
Positive Cocaine
Positive Marijuana
Positive Amphetamines
Positive Benzodiazepines
Positive for Alcohol
Negative for all Substances
Urine Drug Screen Result (other if not listed)
Signature
*
Submit
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