Request Drug Screen
Type of Request
Drug Screen Request
Your Full Name *
Best Number To Contact You *
Your Email Address *
Last 4 Digits Of Your Social *
Your Zip Code *
Date Test Is To Be Taken
Read Carefully! You will be contacted to schedule your appointment by a SureScreen Labs Representative. You MUST bring your Registration Number on or before the scheduled test date in order to be tested. You MUST also have a PICTURE ID with you.
You Have Read & Agree To The Above Requirements *
Yes
No
Message (If Any)
Who is your PTI or AEP Case Manager? *
Thank you! Your submission has been received!
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