Chain of Custody/Drug Test Consent Release Form

I am currently using or have used within the last 30 days the following substances or medications.

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The blood/urine/hair specimen donated by me is my own and has not been substituted by any other person's blood/urine, has not been adulterated through the addition of any foreign substance or compound, and has not been diluted. By signing this consent and release form, I attest that I have read and understand the contents of the form and that the specimen provided by me was sealed in my presence and initialed by me prior to forwarding for laboratory analysis.
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Witness___________________________________ Donor Signature___________________________________________ Date_________________________________________ Date__________________________________________________
Donor Name________________________________ Donor ID#__________________________________________
Address________________________________ City____________________State____ZIP________Tel_______________

Person/Organization Requesting Test___________________________________________________________________
Address_____________________________City_____________________ State____ Zip________Tel________________
____________________________________________________________________________________________________
Specimen Collected by:________________________________________ Title__________________________________
If observed collection, Witness signature________________________________________________________________
Date Collected_____________________________ Time Collected____________________________________________
Specimen Type____________________________ Test Requested____________________________________________
Temperature (must be 90 oF or above and read within 4 min)_________________________________________________
Approximate Length of Hair (ins, cm)___________________Area of Body____________________________________
Color of urine_______________________________ Other Notes_____________________________________________
Referring Physician__________________________________________________________________________________
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WITNESS STATEMENT: This sample was split/sealed in my presence and the label affixed thereto bears the initials and I.D. of the donor.

Witness______________________________________ Donor_________________________________________________

Sample Received by:   

                                                                                                                  Date                     Time           Sealed?

______________________________________________________________ ______________       _______           Y     N ______________________________________________________________ ______________       _______           Y     N ______________________________________________________________ ______________      _______            Y     N _______________________________________________________________ ______________     _______           Y     N
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