CLIENT NAME AND ADDRESS COMPREHENSIVE TOXICOLOGY TEST REQUISITION

Laboratory Director Dr. Xiaoli Chen, MD | CLIA # 39D1099562 Date Collected: Time Collected: 900 Town Center Drive, Ste H50, Langhorne, PA | TEL: (267) 212-2000 | FAX: (267) 212-2005 PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL

ADDRESS PHONE (H) DATE OF BIRTH: (MM/DD/YYYY) SEX SOCIAL SECURITY NUMBER 06/ 1 8 /1990 INSURANCE INFORMATION

I, the undersigned, understand that I am responsible for all co-pays and Commercial Medicare Medicaid Bill Patient Bill Client W/C (Date of Injury): deductibles, and for amounts not covered by insurance. By signing this authorization, I am acknowledging that payment(s) may be made on my behalf to Genesis Diagnostics for any services provided to me by Genesis NAME OF INSURED (IF DIFFERENT FROM PATIENT) PATIENT RELATIONSHIP TO INSURED: Diagnostics. I also allow the release of any medical information necessary to process this claim. SELF SPOUSE DEPENDENT

PRIMARY INSURANCE NAME AND PLAN POLICY NUMBER Patient Signature Required Date ICD9-DX CODES EMPLOYER/GROUP NAME ORDERING PHYSICIAN'S SIGNATURE: (required for Medicaid)

POINT OF CARE TESTING POCT SCREENING PANEL SPECIMEN TYPE Pos. Pos. Pos. Pos. Time Collected: AM / PM AMP COC MTD PCP URINE Date Collected: Saliva BAR MDMA OPI TCA ORAL SWAB Date Collected: BZO MET OXY THC BUP Temperature checked within 4 minutes of collection and is between ALL POCT NEGATIVE PEEL HERE 90 - 100 F or 32 - 38 C Yes No NO POCT PERFORMED CONFIRM POCT RESULTS PRESCRIBED MEDICATIONS PATIENT NOT ON ANY PRESCRIBED MEDICATION

AMPHETAMINE FRISIUM NUCYNTA ULTRAM ADDERALL HALCION DARVOCET NUMORPHAN VERSED CONCERTA KLONOPIN DARVON OPANA VICODIN DEXEDRINE LECTOPAM DEMEROL OPANA ER VICOPROFEN METHYLPHENIDATE DILAUDID OPANA IR TCA RITALIN MADAR DOLOPHINE OXY IR NITRAZEPAM DURAGESIC ADAPIN OXAZEPAM AMYTAL EMBEDA OXYCONTIN AVENTYL PROSOM BUTALBITAL ENDOCET ELAVIL RESTORIL BUTISOL EQUANIL PERCOCET NORPRAMIN ESGIC ROHYPNOL PERCODAN FIORICET SERAX FENTORA SURMONTIL FIORINAL STILNY PROPDXYPHENE TOFRANIL LUMINAL TEMAZEPAM ROXICET VIVACTIL NEMBUTAL VALIUM KADIAN ROXICODONE OTHERS SECONAL XANAX RYZOLT DEPAKOTE BENZODIAZEPINES MUSCLE RELAXANTS LORCET SUBLIMAZE MEPROBROMATE ALPRAZOLAM CARISOPRODOL LORTAB SUBOXONE MILTOWN ATIVAN FLEXERIL MEPERIDINE SUBUTEX CLONAZEPAM SOMA DALMANE OPIATES / DIAZEPAM AVINZA MS CONTIN TYLENOL #3 EURODIN MSIR TYLENOL #4 FLUNITRAZEPAM BUTRANS NORCO TYLOX TEST(S) REQUEST * (See reverse for a description of each optional panel)

Follow Customized Test Profile on File * Genesis Diagnostics provides health care professionals with the option of individual test selection, as opposed to pre-set panels of tests. Please identify the individual drugs and metabolites selected based on medical necessity. FOR LABORATORY Quantitive Confirmation of Drugs by LC/MS/MS USE ONLY Additional Tests Ordered

COMP DRUG PROFILE THC BATH SALTS OTHER: Date Received: DRUG PROFILE A BARBITURATES K2 / SPICE OTHER: DRUG PROFILE B (Etg, Ets) / KRATOM Time Received: AM / PM DRUG PROFILE C

Genesis Diagnostics will confirm the validity of each specimen by analyzying creatinine levels, specific gravity, oxidants and pH. PHYSICIAN SIGNATURE I authorize the above laboratory test(s). I understand that as the practitioner, it is my responsiblility for determining the medical necessity of laboratory tests and for assigning and providing the specific ICD code(s) to support the medical necessity of all laboratory tests ordered. Physician Signature: Date:

REV'20150410 COMPREHENSIVE DRUG PROFILE

STIMULANTS ILLICITS OPIODS OTHER PRESCRIPTIONS Bath Salts/Cathinones Amphetamine Buprenorphine Butylone M ethamphetamine Benzoylecgonine Ketamine Ethylone M ethylphenidate MDMA Fentanyl M DPV Ritalinic Acid MDA Norfentanyl M ethylone Phentermine M DEA M eperidine M ethedrone BARBITURATES PCP Normeperidine M ephedrone Amobarbital THC M ethadone Zolpidem M DPBP Butabarbital OPIATES EDDP Zopiclone Naphyrone Butalbital 6-M AM Pentazocine Zaleplon Pentylone Pentobarbital M orphine Propoxyphene ANTIDEPRESSANTS PVP Phenobarbital Codeine Norpropoxyphene Amitriptyline KAVE / KRATOM Secobarbital Hydrocodone Tapentadol BENZODIAZEPINES Hydromorphone Desmethyltapentadol 7,8-dihydrokavain Alprazolam Norhydrocodone Tramadol M iragynine Alpha-hydroxyalprazolam Oxycodone Desmethyltramadol Nortriptyline 7-hydroxymitragynine Bromazepam Oxymorphone Quetiapine SYNTHETIC CANNABINOIDES / Clonazepam Noroxycodone M USCLE RELAXANTS Ziprasidone SPICE 7-Aminoclonazepam Carisoprodol Desmethylvenlafaxine Diazepam M eprobamate ALCOHOL Nordiazepam Cyclobenzaprine Paroxetine Ethyl Glucuronide Oxazepam Sertraline Ethyl Sulfate(ETS) Temazepam Venlafaxine Flunitrazepam Flurazepam Lorazepam M idazolam Nitrazepam Triazolam DRUG PROFILE A - Minus TCA

STIMULANTS BENZODIAZEPINES ILLICITS OPIODS M USCLE RELAXANTS Amphetamine Alprazolam Cocaine Buprenorphine Carisoprodol M ethamphetamine Alpha-hydroxyalprazolam Benzoylecgoninegonine Norbuprenorphine M eprobamate M ethylphenidate Bromazepam MDMA Fentanyl Cyclobenzaprine Ritalinic Acid Clonazepam MDA Norfentanyl Phentermine 7-Aminoclonazepam M DEA M eperidine OTHER PRESCRIPTIONS Diazepam PCP Normeperidine Dextromethorphan Nordiazepam M ethadone Ketamine Oxazepam OPIATES EDDP Norketamine Temazepam 6-M AM Pentazocine Gabapentin Flunitrazepam M orphine Propoxyphene Pregabalin Flurazepam Codeine Norpropoxyphene Primidone Lorazepam Hydrocodone Tapentadol Zolpidem M idazolam Hydromorphone Desmethyltapentadol Zopiclone Nitrazepam Norhydrocodone Tramadol Zaleplon Triazolam Oxycodone Desmethyltramadol Oxymorphone Sufentanil Noroxycodone Naloxone Naltrexone DRUG PROFILE B - Minus Sedative/Hypnotic Agent/Soma, Anticonvulsants, Barbiturates, TCA

STIMULANTS BENZODIAZEPINES ILLICITS OPIOIDS OTHER PRESCRIPTIONS Amphetamine Alprazolam Cocaine Buprenorphine Dextromethorphan M ethamphetamine Alpha-hydroxyalprazolam Benzoylecgoninegonine Norbuprenorphine Ketamine M ethylphenidate Bromazepam MDMA Fentanyl Norketamine Ritalinic Acid Clonazepam MDA Norfentanyl OPIATES Phentermine 7-Aminoclonazepam M DEA M eperidine 6-M AM Diazepam PCP Normeperidine M orphine Nordiazepam M ethadone Codeine Oxazepam EDDP Hydrocodone Temazepam Pentazocine Hydromorphone Flunitrazepam Propoxyphene Norhydrocodone Flurazepam Norpropoxyphene Oxycodone Lorazepam Tapentadol Oxymorphone M idazolam Desmethyltapentadol Noroxycodone Nitrazepam Tramadol Naloxone Triazolam Desmethyltramadol Naltrexone Sufentanil DRUG PROFILE C - Minus Anticonvulsants, Barbiturates, TCA, Other Drugs

STIMULANTS BENZODIAZEPINES ILLICITS OPIOIDS M USCLE RELAXANTS Amphetamine Alprazolam Cocaine Buprenorphine Carisoprodol M ethamphetamine Alpha-hydroxyalprazolam Benzoylecgoninegonine Norbuprenorphine M eprobamate M ethylphenidate Bromazepam MDMA Fentanyl Cyclobenzaprine Ritalinic Acid Clonazepam MDA Norfentanyl OPIATES Phentermine 7-Aminoclonazepam M DEA M eperidine 6-M AM Diazepam PCP Normeperidine M orphine Nordiazepam M ethadone Codeine Oxazepam EDDP Hydrocodone Temazepam Pentazocine Hydromorphone Flunitrazepam Propoxyphene Norhydrocodone Flurazepam Norpropoxyphene Oxycodone Lorazepam Tapentadol Oxymorphone M idazolam Desmethyltapentadol Noroxycodone Nitrazepam Tramadol Naloxone Triazolam Desmethyltramadol Naltrexone Sufentanil