I, _____________________________, understand that
I agree to provide any specimens needed to conduct the drug test. I understand that if I refuse to undergo drug screening,
I have taken the following drugs or substances within the last 96 hours:
Drug Name | Dosage | Physician |
__________________________________________ | ___________________ | ______________________________________ |
__________________________________________ | ___________________ | ______________________________________ |
__________________________________________ | ___________________ | ______________________________________ |
I hereby ( ) consent ( ) refuse to consent to undergo the drug test(s). I authorize any physician, laboratory, hospital, or medical professional retained by
[PAGE BREAK HERE]
I have read and understood this consent form, and I sign without any coercion or duress by any individual or institution.
Signature:____________________________________ Date:_______________________________
Name:___________________________________________________________________________
Street Address:____________________________________________________________________
City, State, ZIP Code:_______________________________________________________________
Signature of parent/guardian:______________________________Date:_______________________
Parent/guardian name:_______________________________________________________________