Informed Consent Today's Date* MM slash DD slash YYYY Donor and Test InformationI Authorize Results to be Released To:*Potential Employer, Judge/Court or anyone you desire to receive the results of the test. Name* First Last Date of Birth* MM slash DD slash YYYY Last Four Digits of Driver's License or ID*Daytime Phone*Secondary PhoneReason for Testing:* Pre-Employment Random Return to Duty Follow Up Post-Accident Reasonable Suspicion Court Related Other Four Digit PasscodeA four digit passcode is required to inquire about your results over the phone (non-job related results only).FileMax. file size: 20 MB.Upload a copy of your ID. Consent and Test ResultsTESTING AND TEST RESULTS:* Copies of these records/results shall be used by and disclosed to the party(ies) listed. In work related instances, the results will be reported to the employer/potential employer who is requesting the drug test results, the medical review officer (MRO) or other authorized agent(s) requiring the test. If this test is for a work related reason, as the donor, you will be required to obtain a copy of the results directly from your employer. If this test is for a private matter, MedScreens will only disclose these test results to those authorized. For court cases, the donor must list the Judge and/or Attorney(s) that should receive the these test results. If the testing involves a minor, the guardian/legal representative may be entitled to a copy of the result if the adequate documentation is provided. I understand and consent to the fact that MedScreens can/will contact the local authorities in the event that I attempt to drive a vehicle after having a Positive breath alcohol test. I UNDERSTAND THAT ONCE THE COLLECTION PROCESS HAS BEGAN, THE PARTIES LISTED BELOW ARE ENTITLED TO THE RESULTS AND ALL TRANSACTIONS ARE NON-REFUNDABLE. THIS INCLUDES COLLECTIONS IN WHICH THE DONOR IS UNABLE TO SUCCESSFULLY COMPLETE BY THE END OF NORMAL BUSINESS HOURS. INFORMED CONSENT:* I, the donor, being of lawful age, or the guardian/legal representative of the donor to be tested, do hereby voluntarily consent and grant permission to MedScreens, their employees, providers, agents, contractors, representatives and/or laboratories to perform the collection and/or the testing of my specimen. I understand that this process may include the collection of and/or testing of: urine, blood, hair, saliva, sweat, etc. I fully understand that blood testing procedures will involve skin puncture and/or veni-puncture. I certify that I will witness this collection and certify that the specimen provided will be from my body. I understand that to the extent and Recipient(s) of this information, as identified, may not be a “Covered Entity” under Federal Law, the information may no longer be protected by Federal privacy law once it is disclosed to the Recipient and, therefore, may be subject to re-disclosure by the Recipient. AGREEMENT:* By signing below I consent to the information contained on this form. Signature
