CLINIC AUTHORIZATION AND CONSENT
Company: Address:
Phone:
Contact person(s): Complete this form when drug/alcohol testing will be performed by our contracted clinic. Applicant/Employee Name: _________________________________________________________ First
MI
Last
Address: ______________________ City: ____________________ State______ Zip____________ Services Requested: Reason for Test:
Non-DOT Drug Test (5 panel)
Non-DOT Breath Alcohol Test
Pre-employment
Post-Accident
Reasonable Suspicion
Return to Duty
Company contact for test results: _____________________________________ ___________________ Print name
Contact Number
Applicant/Employee Reminders: Refrain from drinking liquids prior to collection Bring current picture ID CONSENT STATEMENT I hereby authorize this company to perform a drug screen or alcohol test to detect the presence of illegal drugs, alcohol, or illegal prescription medication. The result of the test will be analyzed by the Medical Review Officer. I understand that this test will be performed by the company’s contracted clinic/lab and I give full permission for the clinic to release the results of this test to the designated company contact. I understand that drug/alcohol tests are conducted for various reasons including pre-employment, reasonable suspicion, and post-accident and that refusal to submit to drug/alcohol testing will be grounds for termination. I will hold all parties harmless and will not sue nor hold this company responsible for any alleged harm to me or for interfering with my obtaining a job or continued employment due to refusal to test or as a result of test findings. This includes, but is not limited to, possible clerical or laboratory error. This policy and authorization has been explained to me in a language I understand and I have had an opportunity to have my questions answered. I understand that this is a legal and binding document.
Applicant/Employee Signature
Date
Employer Representative Signature
Date
drugscrnconsent_clinic_frm
