Drug Test Supply Order Form

Complete the following form to order drug testing supplies with your LabCorp account number.

*Required Field

 
Contact Information
 
*Your Name:
*Telephone Number: Ext (optional)
*Street Address:
*City:
*State:
*Zip:
*Company Name:
*E-mail Address:
*LabCorp Account Number
Location Code(if applicable)
 

*Please indicate whether you are the LabCorp customer or a collection facility ordering supplies on behalf of the customer.
LabCorp Customer   Collection Site

Supplies Requested

Enter quantity requested for each item ordered.

Specimen Collection Kits (minimum 10 kits – max. 200, increments of 25)

Standard Two –(2) Vial Collection Kit - 200GV

Kit includes:
1 - Biohazard Specimen Shipping Bag
1- Wide Mouth Collection Cup with Temperature Strip
2 - 45ml Urine Specimen Transport Vials

Courier Kit – KT-Cour

Kit includes:
1 - Biohazard Specimen Shipping Bag
1 - 90ml Urine Specimen Container with Temperature Strip
Special Requirements / Comments:
 

Chain-of-Custody Forms (min.10 forms, increments of 25, max 500)
(A)Standard Five –(5) Part Non-Federal COC - 590-5P BC/590 5B BC
(B)Federal Form - 570 DOT
(C) Florida AHCA - FHRS (FL)
(D) Federal Look-a-Like - 580
 

Web Chain-of-Custody (COC) Form Paper (1000 page increments)
(A) Web COC Paper (one case accommodates 333 specimen collections)
 
Employer and Medical Review Officer (MRO) Information
*Required for all chain-of-custody orders (A-D)
   Same as Contact Information Above
Employer:
Street Address:
City:
State:
Zip:
Telephone Number:
 
Required for all DOT and FLHHS chain-of-custody orders (B and C)
   Same as Contact Information Above
MRO Name:
Street Address:
City:
State:
Zip:
Telephone Number:
 

Miscellaneous Supplies
Biohazard Bag with Zipper - CP-906 6x10 (25 bags min – max 100 bags)
White Printer Paper - CP-907 (2500 sheets per box) (max order 1 box)
 
Shipping Information
   Same as Contact Information Above

*Ship to:

*Street Address:

*City:

*State:
*Zip:
*Telephone Number:
 

All supplies shipped via ground unless customer’s overnight courier account information is provided.

Allow 3-10 business days for ground delivery.
 
Customer's courier account number is required for overnight shipment.

Overnight Shipping Request
Account #:

UPS

Airborne

FedEx

Other
Courier Name:

Special Shipping Instructions
 
       Remember Me