Individual Testing Request – pssscreeningsolutions.com

Name

First

Last

Email

Phone Number

Select Drug Test

First Choice – Preferred Appointment Date

First Choice – Preferred Time Window

Second Choice – Preferred Appointment Date

Second Choice – Preferred Time Window

Third Choice – Preferred Appointment Date

Third Choice – Preferred Time Window

Scheduling Flexibility

Emergency Number Payment

Service Location Address

Address Line 1

Address Line 2

City

State

Zip Code

Enter the complete address where testing will be performed. This address will be used to determine the applicable mobile service fee.

Service Location Confirmation

I confirm that the service location address provided above is the exact location where testing is to be performed. I understand that additional travel or service fees may apply if an incorrect service location is provided or if the service location changes after the appointment is confirmed.

Additional Information or Special Instructions

Appointment Request Acknowledgment

I understand that submitting this form does not confirm my appointment. PSS Screening Solutions will contact me to confirm availability and appointment details.

Late Cancellation / Unavailable at Arrival

I understand that a cancellation made less than 24 hours before a confirmed appointment will be charged a late cancellation fee of $50. If a representative of PSS Screening Solutions arrives at the confirmed location and the individual, employer, or group is unavailable to proceed with the scheduled service, an Unavailable at Arrival Fee will be charged at $75. Repeat occurrences will require prepayment for future services.

Private-Pay / Non-DOT Payment

I understand that private-pay and non-DOT testing must be paid in full before service is provided. If I am unable to provide a sufficient specimen and a representative of PSS Screening Solutions must return for another collection, a Return Visit / Recollection Fee of $75 will be applied.

DOT Shy Bladder Process

I understand that if I am unable to provide a sufficient urine specimen for a DOT test, the DOT shy bladder procedure will apply, including a waiting period of up to three hours. I understand that I must remain at the collection site and follow the required DOT shy bladder procedures during this period. If I leave the collection site before the testing process is complete or otherwise fail to follow the required testing process, PSS Screening Solutions will document the circumstances and notify the employer or designated employer representative. The employer will determine whether my actions constitute a refusal to test. Any deliberate attempt to spill, destroy, adulterate, substitute, or otherwise interfere with the specimen or collection process will be documented and reported to the employer or designated employer representative and may result in additional collection procedures and/or a determination of refusal to test by the employer. A DOT Shy Bladder Procedure Fee of $150 will be charged when the DOT shy bladder procedure is required.

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Card

Name on Card

Total

$0.00

Mobile Service Fee

After-Hours / Emergency Service Fee

Holiday Service Fee

Payment and Additional Fees Acknowledgment

I understand that all charges, including additional fees incurred before, during, or after service, must be paid in full. Except where disclosure is required by law, regulation, or an authorized testing process, PSS Screening Solutions may withhold reports, results, certificates, and other client deliverables until the account balance is paid in full.