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Sample Donor Pass With Stamp

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gspilapil032989
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54 views1 page

Sample Donor Pass With Stamp

Uploaded by

gspilapil032989
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DONOR PASS

Participant Name: David Byrne ID: *****8448

Test Reason: RANDOM

Service Provider:
EWR MEDPORT - ELIZABETH, NJ Sun Mon Tue Wed Thu Fri Sat
620 Division Street Open Closed 7:00 AM 7:00 AM 7:00 AM 7:00 AM 7:00 AM 9:00 AM
STE A
Elizabeth, NJ 07201 Close 12:00 AM 12:00 AM 12:00 AM 12:00 AM 12:00 AM 5:00 PM
PH: 973-877-0991 Lunch Closed Closed Closed Closed Closed Closed Closed
FX: 973-710-9149

Test/Service: URINE NONDOT


Account: WKG.NDOT.RECON
Order Number: 77991977 Panel Code: 30LM
Lab Name: Clinical Reference Lab

Test/Service: BREATH NONDOT


Account:
Order Number: 2023032915184 Panel Code: NONDOTBREATHALC PLEASE USE CLINIC HOUSE FORMS
Lab Name: i3screen

! Participant Instructions
- Take the page with you to the specimen Service Provider listed above along with a government issued photo ID.
- Call the Service Provider to confirm operational hours.
- Arrive ONE HOUR before closing time to ensure testing can be completed.

Client/Employer Information: MRO Information:


Remedial Construction Services, LP Janelle Jaworski M.D.
9977 West Sam Houston Parkway North 9501 Northfield Blvd.
Houston, TX 77064 Denver, CO 80238
Phone: 877-585-7366
Fax: 855-253-5666

*NONDOT TEST*Please use FORMFOX, if available, for urine collection and use site's forms for Breath Alcohol Test. Please
follow the notes below:

1. All drug tests must be a SPLIT SPECIMEN collection

2. Complete a confirmation test if breath alcohol result is over .000

3. Fax BAT and CCF to 832.572.5588 or e-mail it to RECON@WorkplaceSafetyScreenings.com

4. Email invoice to AP@WorkplaceSafetyScreenings.com for all services.

Thank you for assisting us. We are thankful for your partnership with Workplace Safety Screenings!

PLEASE DO NOT USE/SCAN THIS PASS BEYOND THE MONTH OF APRIL 2023

PLEASE DO NOT USE/SCAN THIS PASS BEYOND THE MONTH OF APRIL 2023

Can’t print this page? Write down the Order Number(s) and bring it with you to your selected Service Provider.

Case #2023032915185 - Remedial Construction Services, LP - David Byrne Page 1/1

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