AFFIXED LABEL - PT.1 ONLY

Toxicology Requisition Form PATIENT’S LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH

STREET ADDRESS CITY STATE ZIP CODE

PATIENT’S PHONE NO. GENDER  HOME  MOBILE  WORK  MALE  FEMALE

PLEASE SELECT A BILLING OPTION  MEDICARE  INSURANCE  SELF PAY  WORK COMP  INFORMATION ATTACHED PRIMARY INSURANCE CARRIER PRIMARY INSURANCE POLICY/ID PRIMARY INSURANCE GROUP NO.

PATIENT RELATIONSHIP TO INSURED  SELF  SPOUSE  DEPENDENT  OTHER POCT Results: POCT Performed: PRESUMPTIVE PRESUMPTIVE PRESUMPTIVE DRUG NAME NEG POSITIVE DRUG NAME NEG POSITIVE DRUG NAME NEG POSITIVE Amphetamine (AMP) [ ] [ ] Marijuana (THC) [ ] [ ] Phencycliines (PCP) [ ] [ ] Barbiturates (BAR) [ ] [ ] Methadone (MTD) [ ] [ ] Propoxyphene (PPX) [ ] [ ] Benzodiazepines (BZO) [ ] [ ] Methamphetamine (MAMP) [ ] [ ] Tricyclic antidepressants (TCA) [ ] [ ] Buprenorphines (BUP) [ ] [ ] Opiate (OPI/MOP) [ ] [ ] Other [ ] [ ] Cocaine (COC) [ ] [ ] Oxycodone (OXY) [ ] [ ] New Practitioner Acknowledgement and Consent for Standard Testing Protocol Common Panel Options to Choose From:  Comprehensive Confirmation Panel (With Drug Screening)  Comprehensive Confirmation Panel (No Drug Screening)  Extended Confirmation Panel Individual Tests: PRESCRIPTION  Opiates/Semi-Synthetic Opiates (All drugs in Class) PRESCRIPTION  Barbiturates (All drugs in class) PRESCRIPTION  Specimen Validity Tests 6-MAM  Butalbital Specific Gravity  Dextrorphan  Pentobarbital Creatinine  Dextromethorphan  Phenobarbital pH  Codeine  Secobarbital  Extended Confirmation Panel  Hydrocodone  Antidepressants/Tricyclics/Muscle Relaxants (All drugs in class) 4-HYDROXYPENTYL  Hydromorphone  Amitriptyline 6BETA-NALTREXOL  Morphine  Carisoprodol/Meprobamate AM2233  Oxycodone/Noroxycodone  Cyclobenzaprine  ARPIPRAZOLE  Oxymorphone  Desipramine  CITALOPRAM HBR/N-DESMETHYLCITALOPRAM HCL  Synthetic Opiates (All drugs in class)  Doxepin  CLOZAPINE/ N-DESMETHYLCLOZAPINE  Buprenorphine/Norbuprenorphine  Duloxetine COTININE/NORCOTININE  Fentanyl/Norfentanyl  Gabapentin  FLUOXETINE HCL/NORFLUOXETINE HCL  Methadone/EDDP  Imipramine  HALOPERIDOL  Meperidine  Ketamine / Norketamine HU211  Normeperidine  Meprobamate  HYDROXYBUPROPIN  Propoxyphene/Norpropoxyphene  Nortriptyline JWH 019  Tramadol / O-Desmethytramadol  Meprobamate JWH 122  Tapentadol  Nortriptyline JWH015  Stimulants (All drugs in class)  Pregabalin JWH081  Amphetamine (Adderall™)/ Methamphetamine  Illicit Drugs (All drugs in class) JWH200 Benzoylecgonine (cocaine metabolite) 6-MAM (heroin metabolite) JWH203  Methylphenidate (Ritalin™)/ Ritalinic Acid Benzoylecgonine (cocaine metabolite) JWH210 MDA MDA JWH250 MDEA MDEA LSD/ 2-OXO-3-HYDROXY-LSD MDMA MDMA (Ecstasy) MAM2201 MDPV (bath salt) Methamphetamine MITRAGYNINE/7-HYDROXYMITRGYNINE  Mephedrone Phencyclidine (PCP)  NALOXONE  Methylone THCA (marijuana metabolite)  NALTREXONE  Benzodiazepines/Sedatives (All drugs in Class) Synthetic Cannabinoids (K2, Spice)  NORHYDROCODONE HCL  Alpha-hydroxyalprazolam  Hallucinogens (All drugs in class)  OLANZAPINE  Alprazolam THCA  PAROXETINE MALEATE  7-Aminoclonazepam Phencyclidine  PHENTERMINE  Diazepam  Synthetic Cannabinoids (All drugs in class)  QUETIAPINE FUMARATE/NORQUETIAPINE HCL  Lorazepam JWH0184OH RCS4  Nordiazepam JWH0733OH RCS8  Oxazepam  Alcohol (All drugs in class)  RISPERIDONE/9-HYDROXYRISPERIDONE  Temazepam EtG S(-) NICOTINE  Zolpidem (Ambien™) UR-144  Zopiclone  VENLAFAXINE HYDROCHLORIDE/O-DESMETHYLVENLAFAXINE ICD-10 Codes Diagnosis SPECIMEN INTAKE DETAILS COLLECTOR NAME: COLLECTOR INITIAL:

DATE: TIME: F° 90.5 - 100 Patient consent: I certify that I have voluntarily provided a fresh, unadulterated urine specimen for analytical testing. The information provided on the label affixed to the specimen bottle is accurate. I hereby authorize payment of medical insurance benefits to SDI Labs and/ or its affiliates. I understand that if my insurance company pays me directly for the services provided by SDI Labs and/ or its affiliates that I am responsible for forwarding such payment to SDI Labs and/ or its affiliates. I understand that I am responsible for all charges including deductible/co-payment as required by my plan.

Patient Signature Date As part of my medical practice’s prescription medication management and compliance protocols, I hereby request and authorize SDI Labs and/ or its affiliates to establish for me a customized toxicology testing panel analysis to test patient specimens from my practice for therapeutic drug monitoring (TDM) via quantitative confirmatory testing by LC/MS/MS for each of the analytes/metabolites selected by me indicated by either filling in the boxes or crossing out any that are not desired. I understand and hereby acknowledge that I only order tests that I believe to be medically necessary for each of my patients in order to monitor their drug compliance protocol, and I am requesting the above panel accordingly.

Practitioner Signature Date