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    DRUG TESTING CONSENT FORM final

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    KennethPeralta

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    © All Rights Reserved
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    DRUG TESTING CONSENT FORM final

    Uploaded by

    KennethPeralta
    0 views1 page

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    © © All Rights Reserved

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    DRUG TESTING CONSENT FORM final

    Uploaded by

    KennethPeralta

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    MKC DRUG TEST LABORATORY

    PUROK MAGSANOC, CAPITOL AVE., MANKILAM, TAGUM CITY


    Tel. No. (084) 216-0021

    DRUG TESTING CONSENT FORM

    Code No.: __________________

    Name: ____________________________________________ Date: ___/___/___/ Time: ________


    Surname First Name Middle Name (mm/dd/year)

    Address: __________________________________________________ Tel. No. _______________

    Birthdate __________________ Age: ________ Sex:[ ] Male [ ] Female Civil Status _________

    Company: _______________________________________________________________________

    Purpose of Drug Test:


    [ ] Employment [ ] Private [ ] Government
    [ ] License [ ] Driver’s [ ] Firearm’s
    [ ] Student [ ] Secondary School [ ] Tertiary School
    [ ] Candidate for Public Office whether appointee or elected
    [ ] Persons apprehend or arrested for violating the provisions of this Act
    [ ] Persons charge before the prosecutor’s office with a criminal offense having an imposable
    penalty of imprisonment of not less than six(6) yrs. and one (1) day
    [ ] Others (pls. specify) ______________________________

    Instructions: Answer the questions below by checking the appropriate spaces below your answer
    Afterward, read the statements below signing the two for your signature.

    Have you taken medication or drugs in the past 30 days? [ ] Yes [ ] No


    Have you ingested any alcoholic beverage in the past 24 hrs. [ ] Yes [ ] No.
    If you are taking medication of drugs list these items below

    ________________________________________________________________________________

    I hereby consent and agree to give sample of my (Pls. Encircle)


    a) Urine b.) Blood c.) Saliva d.) Hair e) Sweat f.) Tissues
    The result of any tests performed shall be provided to the requesting office or agency
    my signature below acknowledges that I have read and understood the foregoing
    statement and I have answered all the questions truthfully.

    Date: ____/____/____ Signature: _________________________


    (mm/dd/year) Client/Donor/Subject

    I hereby consent and agree that my ____________ specimen, if found positive be sent to duly
    accredited/licensed Confirmatory Laboratory for confirmatory tests.

    I hereby acknowledge that the _________________ sample is my own and that the samples were
    sealed in my presence.
    These samples are to be tested for dangerous drugs.

    Date: ____/____/____ Signature: _________________________


    (mm/dd/year) Client/Donor/Subject

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