Person to be screened:
*
*
*
(first, middle, last name)
Social Security #:
Referring agency:
Case #:
Recipient (client) ID#:
DHS Clients Only:
Please select...
Protective Services
Foster Care
Person Making Referral:
*
Load Number: if applicable
Email:
*
Phone #:
*
(
)
*
-
*
Fax #:
(
)
-
Type of ONE-TIME SCREENING requested:
Please select...
91048EOV Span Ultra 18 Panel
EtG alcohol screen
Hair drug screen
Other: (see below)
Other:
Special instructions - additional screens:
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