Authorization Form

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Analytical Testing Group®

***ATG does not practice medicine, prescribe medicine, treat injuries, or diagnose patients.***

DRUG TESTING-COUNSELING-PATERNITY TESTING-DUI SERVICES

Home
Services
DUI School / Risk Reduction
On-Site Testing Services
Education and Training
DNA Paternity Testing
Authorization Form
Compliance & News Updates
About Us
Contact Us

Home
Services
DUI School / Risk Reduction
On-Site Testing Services
Education and Training
DNA Paternity Testing
Authorization Form
Compliance & News Updates
About Us
Contact Us

AUTHORIZATION FORM

(to request service at our clinic or onsite please complete info below)

Company Name

Address

City, State,Zip

Phone Number

Fax Number and Email address

Name of Person/Contact Authorizing Services

Name of Employee/Donor being Tested

Type of Service Need

Basic Employment PhysicalDOT PhysicalDOT Drug ScreenDOT Breath Alcohol5 Panel Urine Drug ScreenHair AnalysisDNA Paternity TestHearing/ AudiometryInstant 5 PanelInstant- 5, 9, 10, 12 or 16Drug and Alcohol testDrug Screen and PhysicalUnknown Substance TestingPaternity Test

Time Employee was notified to test

Hours : Minutes

Date of Request

Comments or Special Instruction

Is this for DOT purposes (CDL, Pilot, Railroad, Coast Guard, Transit, etc)

YesNo

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