DONORS DETAILS
Donor Name
Salutation:
Please state...
Mr
Mrs
Miss
Ms
Contact Number
Date of Birth
Court Filing Date
INVOICE & RESULT INFORMATION
Split invoicing incurs a charge of £20.00 + VAT per party. Please provide details upon completion of this form and send in separate documentation to info@trimegalabs.com. We require for all parties: name of firm and fee earner, relevant reference number, address, telephone and fax numbers. We will not be able to split invoices without this information.
Split invoicing:
Yes No
Results & Invoice/s to be sent to:
Name
Post Code
Organisation
Tel No
Reference
Fax No
Address
Email Address
Testing kit to be dispatched to/collection location:
Name
Postal Code
Organisation
Tel No
Address
Fax No
Email
Opposing Solicitor Details:
Name
Postal Code
Organisation
Tel No
Reference
Fax No
Address
Email
Automatic email updates will be generated by email to the address you have supplied above to update you on the progress of your test. Would you like to receive these emails?
Yes No
DRUG TESTING (complete if applicable)
DRUGS TO BE TESTED FOR (tick as appropriate)
REQUIRED DURATION OF DRUG TESTING (tick as appropriate)
TYPE OF TEST REQUIRED (tick as appropriate)
ALCOHOL ABUSE TESTING (complete if applicable)
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 2-3 weeks (CDT / LFT) and/or as far back as a hair sample will allow (FAEE Test). Trimega Laboratories continues to set the highest standard in Hair Alcohol Testing by the introduction of EtG to its suite of alcohol analysis. To assist in your choice of the most appropriate tests for your case, we have categorised our Hair Alcohol Testing range into three standards (Bronze, Silver & Gold) based on scientific test research.
ALCOHOL QUESTIONS (please complete):
TEST(S) REQUIRED (tick as appropriate)
ADDITIONAL
EXPERT WITNESS STATEMENT (tick as appropriate)
Expert Witness Statement - Trimega Laboratories include within the testing charges a Certificate of Analysis and a summary with an extended report. We can provide 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 additional cost and is available for both Drug and Alcohol tests.
TRIMEGA NURSE SAMPLE COLLECTION (tick as appropriate)
Sample Collection - 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 as an extra cost if you have not requested for The Complete Package. Please indicate YES or NO if you wish to have your client's samples collected by one of our nurses.
Yes No
If you have indicated YES, please indicate the initial point of contact when arranging the sample collection:
Solicitor/ Social Worker
Other If you have indicated 'Other', please provide their status (e.g., donor)
Name of contact indicated above
Contact Tel
If you have indicated YES, please provide any preferred appointment dates:
Preferred appointment dates (if any)
(please note that any appointment dates indicated above are not guaranteed and are subject to nurse availability)
YOUR DETAILS
If your details are different from the details provided in the "Results & Invoice to be sent to" section, please provide us with your full name and contact details.
Your Name
Contact Tel
Email