Drug Screen Form

Drug Testing Registration Scheduling

Test Registration is required for drug screening.

Testing locations do not accept payment and require a test donor pass to conduct a drug test.

The Test Registration / Donor pass will be e-mailed to you with the test address, date and time. (take this form with you)

All information is confidential and secure.

Testing Info

Testing Location *Heavenly Hands Screening, 1901 North Frontage Rd Suite 4, Vicksburg, MS 39180Mobile onsiteTesting location selected below will be used to schedule the test you have selected.

Requested Date of Testing *

Requesting Time of Testing *

Hours

Minutes

Results Email Address *Please provide the e-mail address to send the confidential test results.

Who will be testing?

Reason for testing *

DOT only, Select Agency *

FMCSA Employer/Company Name

CDL State *0 / 20

CDL Number *0 / 13

Tester Name Info

Full Name *

Email *

Phone Number *0 / 10

Social security *0 / 9

DOB *

What Test is Needed?Select the number of tests.

5 panel NON-DOT Drug and Alcohol Blood Test - $100

10 panel DOT Drug and Alcohol Blood Test - $100

5 panel DOT Drug and Alcohol Blood Test - $100

10 panel NON-DOT Drug and Alcohol Blood Test - $100

10 panel DOT Drug Screen Urine Test- $95

10 panel NON- DOT Drug Screen Urine Test- $55

5 panel NON- DOT Drug Screen Urine Test- $55

5 panel DOT Drug Screen Urine Tests - $95

Total Purchase order

Contact/Company Info

Phone Number *0 / 10

Company Email *Where donor pass/authorization form will be sent.

Contact Full Name *

Company Name

Company Phone Number *0 / 10

Payment Info

Credit / Debit Card *

By checking this box, you are agreeing to our Terms of Service.*

I understand that once my information and payment has been processed this order will be non-refundable. I have read and understand the Terms and Conditions and understand that All Sales are Final and no refunds will be issued.

Please do not fill in this field.