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HAIR TESTING FORM

Tamper-Evident Bag No.

0987654321

Reference / Barcode No.

1234567890

Requesting Company

South Eastern Trust

Donor Ref CCN

7025

Collection Org.

NIVHA

Donor Date of Birth

12/09/1985

Donor Name

Joe Bloggs

Donor Gender

Male

Is Donor verified?

YES

Donor ID Type

Driving Licence

Donor Declaration: The collection / testing procedure has been explained to me and I CONSENT to provide a sample of Hair for Testing.

Declared Medication (within the past 14 days)

	Drug / Brand	When Taken
#1	Co Codamol	Today
#2	Medicinal Cannabis	Today
#3	Merhadone	Yesterday
#4
#5
#6
#7
#8

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Chemical Treatment

YES

Hair Sample Submitted

Head

Chemical Treatment

Dyed

Chemical Treatment details:

When was hair last treated?

2 weeks ago

List products used (if known)

Sun in

No. of Samples taken

Two

Detection Period (Months)

3 Months

Requested Panel(s)

H-DP2

H-DAS

Single Drug Only (please specify)

Methadone

Receiving Laboratory

Cansford

Collector Declaration I certify that the specimen(s) which accompany this form are those provided by the donor above, bear the identification numbers detailed above and they have been collected in accordance with chain of custody recommendations and instructions provided by NIVHA Laboratory Services Ltd.

Consent of Donor to Submit Sample. I certify that the specimens which accompany this form are my own and were provided by me to the collector. I witnessed the specimen(s) being sealed into tamper evident package(s) bearing the above reference number. I confirm that the information provided on this form and on the samples is correct correct and I consent to the specimens being submitted to the laboratory for testing. I understand that the result of the tests will only be made available to the requesting organisation and their authorised representatives.