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? *

CAPTCHA (Enter the code from the image below):

var _gaq = _gaq || []; _gaq.push(['mofuse._setAccount', 'UA-249256-20']); _gaq.push(['mofuse._setCustomVar', 1, 'siteHash', '1f7193a13d5e3b569b317ad3954423e3', 2]); _gaq.push(['mofuse._trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); mofuse.com