Request Drug Screen

Type Request

Your Full Name *

Best Number To Contact You *

Your Email Address *

Last 4 Digits Of Your Social *

Your Zip Code *

Date Test Is To Be Taken

Read Carefully! You will be contacted to schedule your appointment by a SureScreen Labs Representative. You MUST bring your Registration Number on or before the scheduled test date in order to be tested. You MUST also have a PICTURE ID with you.

You Have Read & Agree To The Above Requirements *

Yes

No

Message (If Any)

Who is your PTI or AEP Case Manager? *

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