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MUST COMPLETE ALL FOLLOWING SECTIONS PATIENT INFORMATION PRACTICE INFORMATION

______Last Name First Name MI Facility/Group Referring Physician

______/______/______Social Security: ______-______-______☐ Male ☐ Female ______Date of Birth Address NPI Provider Nr. ______Address DIAGNOSTIC CODES (ICD-10 codes): ______☐ Self-Pay (attach Information) ☐ Commercial Insurance (attach copy) ☐ W/C (Date of Injury): ______☐ Medicare (attach copy of Insurance Card) I certify that I have voluntarily provided a fresh unadulterated dried blood spot specimen for analytical testing. The information provided on this form and on the label affixed to the specimen bottle is accurate. I authorize lab to release the results of this testing to the ordering physician. I also authorize lab to bill my insurance provider and to receive payment of benefits for the tests ordered by my physician. I further authorize lab and the ordering physician to release to my insurance provider any medical information necessary to process this claim. I acknowledge that lab may be an out-of-network facility with my insurance provider. Patient Signature (or Legal Guardian): ______Date: ______TEST PANELS (please check desired drugs/drug classes for testing): ☐ TEST FOR ALL CLASSES BELOW (1-24): o Citalopram (Celexa) ☐ 9. DECONGESTANTS o Clomipramine (Anafranil) ☐ 1. NARCOTIC / OPIATES o (Robitussin) o Desipramine (Norpramin) o Pseudoephedrine (Sudafed) o Acetaminophen (Tylenol) o Desvenlafaxine (Pristiq) o (Butrans) o Doxepin (Silenor, Prudoxin) ☐ 10. APPETITE STIMULANTS o Butorphanol (Stadol) o Duloxetine (Cymbalta) o Marinol (Dronabinol Extract) o Codeine (Tylenol #3) o (Prozac) o Phentermine (Suprenza) o Fentanyl (Duragesic, Actiq) o Fluvoxamine (Luvox) ☐ 11. ANTIDOTES o Hydrocodone (Norco, Vicodin) o Imipramine (Tofranil) o Naloxone (Revia, Vivitrol) o Hydromorphone (Dilaudid) o D-L-Kavain, , () o Naltrexone (Evzio) o Ketamine (Ketalar) o Milnacipran (Savella) ☐ 12. ILLICITS o (Levo-Dromoran) o Mirtazapine (Remeron) o 6-MAM (Heroin) o Meperidine (Demerol) o Nortriptyline (Pamelor) o Acetyl-Fentanyl o Methadone (Methadose, Dolophine) o Paroxetine (Paxil, Pexeva) o Alpha-PVP (“Flakka”) o Morphine (MS Contin, Kadian, Duramorph) o Sertraline (Zoloft) o Carfentanil (Wildnil®) o Oxycodone (Percocet, Roxicet, Oxycontin) o Trazodone (Oleptro) o (“Coke”) o Oxymorphone (Opana) o Venlafaxine (Effexor) o DMT (Tryptamine, Psilocybin) o Propoxyphene (Darvon) o Vilazodone (Viibryd) o MDA (Tenamfetamine) o Tapentadol (Nucynta) o Vortioxetine (Trintellix) o Tramadol (Ultram) o MDEA (“Eve”) ☐ 5. DEPRESSANTS o MDMA (Ecstasy, “Molly”) ☐ 2. o (Dalmane) o MDPV (Bath Salts) o (Xanax, Niravam) o (Versed) o Mephedrone (Bath Salts) o Buspirone (Buspar) o (Sonata) o Methamphetamine (Meth) o (Librium) o (Ambien) o Methylone (Bath Salts) o (Onfi) o , Eszcopiclone (Zimovane, Lunesta) o Mitragynine (Kratom) o (Klonopin) ☐ 6. ANTI-CONVULSANTS o PCP (Phencyclidine) o (Valium, Diastat) o (Tegretol) o THC (Marijuana) o (Prosom) o (Neurontin) o U-47700 (Synthetic Opioid) o (Rohypnol) o (Lamictal) o (Ativan) ☐ SPICE (K2/SPICE) o (Keppra) o (Serax) o 5-Fluoro NPB-22 o (Trileptal) o (Centrac) o AB-FUBINACA o (Dilantin, Phenytek) o (Restoril) o AM-2201 o (Lyrica) o (Halcion) o FDU-PB-22 o (Mysoline) o HU-210 ☐ 3. ANTI-PSYCHOTICS o Tiagabine (Gabitril) o JWH-019 o Aripiprazole, Brexpiprazole (Abilify, Rexulti) o (Topamax, Qudexy XR) o JWH-073-4-Hydroxybutyl o Asenapine (Saphris, Sycrest) o Valproic Acid (Depakote) o JWH-081 o (Thorazine) o (Zonegran) o JWH-122 o (Clozaril) ☐ 7. MUSCLE RELAXANTS o JWH-18-5-Pentonic Acid o Fluphenazine (Permitil) o (Liorsel) o JWH-18-5-Pentanyl o (Haldol) o (Soma) o JWH-250-5-OH-Pentanyl o Iloperidone (Fanapt, Zomaril) o Cyclobenzaprine (Flexeril) o MMB-CHMICA o Lurasidone (Latuda) o Metaxalone (Skelaxin, Metaxall) o Olanzapine (Zyprexa) ☐ 13. o Methocarbamol (Robaxin) o Perphenazine (Trilafon) o (Amytal) o Quetiapine (Seroquel) ☐ 8. STIMULANTS / ADHD o (Butisol) o Risperidone (Risperdal) o Atomoxetine (Strattera) o (Axotal) o (Mellaril) o Amphetamine (Adderall) o (Luminal) o Thiothixene (Navane) o Caffeine (Viviran, Cafcit) o (Nembutal) o Ziprasidone (Geodon) o Ephedrine (Bronkaid) o (Seconal) ☐ 4. ANTI-DEPRESSANTS / SSRI / SNRI / TCA o Guanfacine (Tenex, Intuniv) ☐ 14. DIRECT BIOMARKERS o Methylphenidate (Ritalin) o Amitriptyline (Elavil) o Cotinine (Nicotine) o Lisdexamfetamine (Vyvanse) o Amoxapine (Asendin) o ETG (Ethanol Metabolite) o Ritalinic Acid (Methylphenidate) o Bupropion (Wellbutrin) o ETS (Ethanol Metabolite) Page 1 of 2

☐ 15. ANTI-INFLAMMATORY / NSAIDs ☐ 16. CARDIOVASCULAR (cont’d) ☐ 19. DIABETIC o Allopurinol (Aloprim) o Eletriptan (Relpax) o (Glucotrol) o Celecoxib (Celebrex) o Enalaprilat (Vasotec, Renitec) o Glyburide (Glynase) o Cetirizine (Zyrtec) o Ezetimibe (Zetia, Ezetrol) o Linagliptin (Tradjenta) o Chlorpheniramine (Chlor Trimenton) o Fenofibrate (Tricor) o Metformin (Glumetza) o Colchicine (Colcrys,Mitigare) o (Tambocor) o (Starlix) o Desloratadine (Clarinex) o Gemfibrozil (Lopid) o Pioglitazone (Actos) o Diclofenac (Voltaren, Cambia, Solaraze) o (Amaryl) o (Prandin) o (Benadryl, Banophen) o Hydrochlorothiazide (Microzide) o Rosiglitazone (Avandia) o Etodolac (Lodine) o Irbesartan (Avapro) o Saxagliptin (Onglyza) o Febuxostat (Uloric) o Labetalol (Normodyne) o Sitagliptin (Januvia) o Fexofenadine (Aller-ease) o Lisinopril (Prinivil) o Hydroxychloroquine (Plaquenil) o Losartan (Cozaar) ☐ 20. DIURETICS / INCONTINENCE o Hydroxyzine (Vistaril) o Metoprolol (Lopressor) o Acetazolamide (Daimox Sequels) o (Advil) o Nadolol (Corgard) o Alfuzosin (Uroxatral) o Indomethacin (Tivorbex) o (Adalat) o Canrenone (Contaren) o Loratadine (Claritin) o Olmesartan (Benicar) o Chlorothiazide (Diuril) o Meloxicam (Mobic) o Pentoxifylline (Pentoxil) o (Lasix) o Montelukast (Singulair) o Propranolol (Inderal) o Indapamide (Losol) o Naproxen (Aleve, Naprosyn) o (Ranexa) o (VESIcare) o Olopatadine (Patanol, Pataday) o Rivaroxaban (Xarelto) o Torsemide (Demadex) o Oxipurinol (Oxyprim) o Simvastatin (Zocor) o (Dyrenium) o Piroxicam (Feldene) o Telmisartan (Micardis)

o (Phenergan, Phenadox) o Terazosin (Hytrin) o Sumatriptan (Alsuma) o Ticagrelor (Brilinta) ☐ 21. PDE (Phosphodiesterase inhibitors) o Tofacitinib (Xeljanz, Jakvinus) o Valsartan (Diovan) o Sildenafil (Viagra, Revatio) o (Verelan) o Vardenafil (Levitra) ☐ 16. CARDIOVASCULAR o Warfarin (Coumadin) o Tadalafil (Cialis, Adcirca) o Acebutolol (Sectral) o (Nexterone, Pacerone) ☐ 17.ANTIBIOTICS / UTIs ☐ 22. CORTICOSTEROIDS / HORMONE o (Norvasc) o (Enablex) THERAPY o Apixaban (Eliquis) o Itraconazole (Sporanox) o Budesonide (Entocort) o Atenolol (Tenormin) o Nitrofurantoin (Macrobid) o Dexamethasone (Ozurdex) o Atorvastatin (Lipitor) o Levothryoxine (Synthroid) o Benazepril (Lotensin) ☐ 18. GASTROINTESTINAL / DIETARY o Finasteride (Proscar) o Bisoprolol (Zebeta, Concor) o Prednisolone (Omnipred) o Biotin (Vitamin B7/H) o Candesartan cilexetil (Biopress, Atacand) o Raloxifene (Evista) o Famotidine (Pepcid) o Candesartan (Biopress, Atacand) o Carvedilol (Coreg) o Hyoscyamine (Levsin) o Cilostazol (Pletaal) o Lansoprazole (Prevacid) ☐ 23. ANTI-NEOPLASTICS / CANCER THERAPY o Clopidogrel (Plavix) o Metoclopramide (Reglan) o Methotrexate (Trexall) o Dabigatran (Pradaxa) o Omeprazole (Losec, Prilosec) o Ondansetron (Zofran) o (Cardizem) o Ondansetron (Zofran) o Pantoprazole (Protonix) o Dipyridamole (Persantine) ☐ 24. DEMENTIA (Parkinson’s/Alzheimer’s) o Ranitidine (Zantac) o Doxazosin (Cardura) o Donepezil (Aricept) o (Multaq) o Rivastigmine (Exelon) o Ropinirole (Requip)

SAMPLE HANDLING The following MUST be completed (check all that apply): Time Collected: ______AM/PM Date Collected: ______ Desired Drug Panels marked above. Separate Medication List provided.  CleanAssure™ test by dried blood spot (use 4-tip Microsampling Kit). Collected by: ______ CleanAssure™ specimen must be shipped sealed in foil bag with desiccant.

AUTHORIZATION & ATTESTATION By signing below, I authorize Alcala Testing to perform LC-MS/MS testing for qualitative and quantitative confirmation of positive and negative results. I attest that the requested testing is medically necessary and appropriate based on the patient’s diagnosis and treatment plan. I have personally completed the diagnosis codes above to indicate the accurate diagnosis for this patient. I have not already provided this testing on the date of collection. Physician Signature: ______Date: ______

Form_DBS-COMPREHENSIVE-003 Rev 3. 07/2018 ORIGINAL COPY – ALCALA

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