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Instruction form

Please complete all areas of this request form to ensure that we can provide you with a detailed quotation. Please note the permanent fields that are required (yellow boxes). Upon receipt of your form, your request will be dealt with immediately and a quotation will be sent to you accordingly.

Donor's Details
Customer's Invoice and Result Information
Results and Invoice to be sent to
   

Automatic updates will be generated by email to you. Please indicate YES or NO if you wish to receive these updates.
 Yes     No

Details of sample collection location or where testing kit is to be dispatched (if applicable)
Opposing Solicitor Details
Hair Drug Testing
Drugs to be tested for (tick as appropriate)
Amphetamines * Opiates
Methamphetamines * Oxycodone
Cocaine Hydrocodone
Phencyclidine (PCP) Hydromorphone
Cannabis Other
* For Amphetamines and Methamphetamines , if one of these is requested,
we will test for both and charge for doing two tests.
Studies have shown that head hair grows approximately 1cm per month. This growth rate varies slightly (estimated at +/- 0.2cm per month). Standard screening tests cover approximately 90-day periods (3cm); however a more detailed month by month analysis can be performed by testing individual 1cm sections enabling a historic record to be established as far back as the hair sample will allow.
Type of test required (tick as appropriate)
Standard Test - A length of hair can be analysed in order to determine the presence/absence of substances within a specific time period (i.e., 0-90 days, 90-180 days, 180-270 days, 270-360 days).
Segmented Test - Lengths of hair can be segmented into sections and analysed in order to determine the presence/absence of substances within a specific time period (0-30 days, 30-60 days, 60-90 days).
Required duration of drug testing (tick as appropriate)
1 month 9 months
3 months 6 months
Other  
Alcohol Abuse Testing
It is now possible to assess people who have been drinking heavily or using alcohol regularly (defined as at least 60 grams of alcohol per day) on a routine basis for a minimum of two to three weeks (CDT/LFT) and/or as far back as a hair sample will allow (HAT). The Complete Package is a combination of CDT/LFT/HAT including sample collection and expert witness statement to gain a full picture.
Test(s) required (tick as appropriate)
Carbohydrate Deficient Transferrin (CDT) Liver Function Test (LFT)
Hair Alcohol Test (HAT) Complete Package
Has donor had history of excessive alcohol consumption?
 Yes      No    
Abstinent since Date Other Reason
Expert Witness Statement Required (tick as appropriate)
Trimega Laboratories include within the testing charges a Certificate of Analysis and a summary with an extended report as statement. We can compose an Expert Witness Statement for court purposes as and when it is required that includes the clarification of the diagnostic findings. This is charged at an extra cost and is available for both Drug and Alcohol Testing.
Drug Alcohol
Sample Collection (tick as appropriate)
Trimega Laboratories provide a network of nurses who may attend your office or your client's home to collect the sample. The cost of collection is charged at an extra cost.
 Yes      No    
Please indicate the initial point of contact when arranging the sample collection:
Donor Solicitor/ Social Worker
Other  
 
Date: Sunday 11, May 2008  
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