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Columbus, Ohio 43214
614-459-2307 Ph., 614-442-0578 Fx.

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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.

___________________________________________________________________________________________________

The blood/urine/hair/other 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.
_____________________________________________________________________________

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__________________________________________________________________________________
____________________________________________________________________________________________________

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:   

                                                                                                                                                                                                       Sealed?
Name Date Time Yes No
         
         
         
         

________________________________________________________________________________________

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