Consent to Drug Testing
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Consent to Drug Testing

Consent to Drug Testing

I, _____________________________, understand that needs my authorization to conduct a drug test . I have been informed of and understand the testing procedure.

I agree to provide any specimens needed to conduct the drug test. I understand that if I refuse to undergo drug screening, I may be subject to immediate terminationI may be expelled from school. I understand too that if I consent to the test and the results are positive, the results will be reported to and I may be for violation of 's drug policy. This policy exempts the use of legally prescribed medications taken under the direction of a physician.

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 to conduct this drug test and to provide the results to . I release , any person affiliated with , and any institution or person conducting the drug test from liability. I give this consent pursuant to all state and federal privacy statutes and waive all rights to nondisclosure of this test record and results only to the extent of the disclosures authorized in this form.

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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:_______________________________________________________________

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