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) I certify that I have voluntarily provided a fresh unadulterated urine/dried blood/oral fluid specimen for analytical testing. The information provided on this form and on the label affixed to the specimen 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 specimen type & drugs/drug classes for testing): ☐ URINE SPECIMEN ☐ DRIED BLOOD SPOT SPECIMEN (all 4 tips) ☐ ORAL FLUID SPECIMEN o Methylphenidate (Ritalin) ☐ URINALYSIS/VALIDITY TESTING (Urine) ☐ 4. ANTI-DEPRESSANTS / SSRI / SNRI / TCA o Lisdexamfetamine (Vyvanse) o Amitriptyline (Elavil) ☐ TEST FOR ALL CLASSES BELOW (1-26): o Ritalinic Acid (Methylphenidate) o Amoxapine (Asendin) ☐ 9. DECONGESTANTS ☐ 1. ANALGESICS / OPIATES o Bupropion (Wellbutrin) o Acetaminophen (Tylenol) o Citalopram (Celexa) o Dextromethorphan (Robitussin) o Buprenorphine (Butrans) o Clomipramine (Anafranil) o Pseudoephedrine (Sudafed) o Butorphanol (Stadol) o Desipramine (Norpramin) ☐ 10. APPETITE STIMULANTS o Codeine (Tylenol #3) o Desvenlafaxine (Pristiq) o Marinol (Dronabinol Extract) o Doxepin (Silenor, Prudoxin) o Fentanyl (Duragesic, Actiq) o Phentermine (Suprenza) o Hydrocodone (Norco, Vicodin) o Duloxetine (Cymbalta) o Hydromorphone (Dilaudid) o Fluoxetine (Prozac) ☐ 11. ANTIDOTES o Ketamine (Ketalar) o Fluvoxamine (Luvox) o Naloxone (Evzio) o Levorphanol (Levo-Dromoran) o Imipramine (Tofranil) o Naltrexone (Revia, Vivitrol) o D-L-Kavain, Yangonin, Methysticin (Kava) o Meperidine (Demerol) ☐ 12. ILLICITS o Methadone (Methadose, Dolophine) o Milnacipran (Savella) o Mirtazapine (Remeron) o 6-MAM (Heroin) o Morphine (MS Contin, Kadian, Duramorph) o Acetyl-Fentanyl o Oxycodone (Percocet, Roxicet, Oxycontin) o Nortriptyline (Pamelor) o Paroxetine (Paxil, Pexeva) o Alpha-PVP (“Flakka”) o Oxymorphone (Opana) o Carfentanil (Wildnil®) o Propoxyphene (Darvon) o Sertraline (Zoloft) o Trazodone (Oleptro) o Cocaine (“Coke”) o Tapentadol (Nucynta) o DMT (Tryptamine) o Tramadol (Ultram) o Venlafaxine (Effexor) o Vilazodone (Viibryd) o MDA (Tenamfetamine) ☐ 2. BENZODIAZEPINES o Vortioxetine (Trintellix) o MDEA (“Eve”) o Alprazolam (Xanax, Niravam) o MDMA (Ecstasy, “Molly”) o Buspirone (Buspar) ☐ 5. DEPRESSANTS o MDPV (Bath Salts) o Chlordiazepoxide (Librium) o Zaleplon (Sonata) o Mephedrone (Bath Salts) o Clobazam (Onfi) o Zolpidem (Ambien) o Methamphetamine (Meth) o Clonazepam (Klonopin) o Zopiclone, Eszcopiclone (Zimovane, Lunesta) o Methylone (Bath Salts) o Mitragynine (Kratom) o Diazepam (Valium, Diastat) ☐ 6. ANTI-CONVULSANTS o PCP (Phencyclidine) o Estazolam (Prosom) o Carbamazepine (Tegretol) o Flurazepam (Dalmane) o THC (Marijuana) o Gabapentin (Neurontin) o U-47700 (Synthetic Opioid) o Flunitrazepam (Rohypnol) o Lamotrigine (Lamictal) o Lorazepam (Ativan) o Levetiracetam (Keppra) ☐ SPICE CANNABINOIDS (K2/SPICE) o Midazolam (Versed) o Oxcarbazepine (Trileptal) o 5-Fluoro NPB-22 o Oxazepam (Serax) o Phenytoin (Dilantin, Phenytek) o AB-FUBINACA o Prazepam (Centrac) o Pregabalin (Lyrica) o AM-2201 o Temazepam (Restoril) o Primidone (Mysoline) o FDU-PB-22 o Triazolam (Halcion) o Tiagabine (Gabitril) o HU-210 ☐ 3. ANTI-PSYCHOTICS o Topiramate (Topamax, Qudexy XR) o JWH-019 o Aripiprazole (Abilify) o Valproic Acid (Depakote) o JWH-073-4-Hydroxybutyl o Asenapine (Saphris, Sycrest) o Zonisamide (Zonegran) o JWH-081 o JWH-122 o Chlorpromazine (Thorazine) ☐ 7. MUSCLE RELAXANTS o Clozapine (Clozaril) o JWH-18-5-Pentonic Acid o Baclofen (Liorsel) o JWH-18-5-Pentanyl o Fluphenazine (Permitil) o Carisoprodol (Soma) o Haloperidol (Haldol) o JWH-250-5-OH-Pentanyl o Cyclobenzaprine (Flexeril) o MMB-CHMICA o Iloperidone (Fanapt, Zomaril) o Metaxalone (Skelaxin, Metaxall) o Lurasidone (Latuda) o Methocarbamol (Robaxin) ☐ 13. BARBITURATES o Olanzapine (Zyprexa) o Amobarbital (Amytal) ☐ 8. STIMULANTS / ADHD o Perphenazine (Trilafon) o Butabarbital (Butisol) o Quetiapine (Seroquel) o Atomoxetine (Strattera) o Butalbital (Axotal) o Risperidone (Risperdal) o Amphetamine (Adderall) o Phenobarbital (Luminal) o Thioridazine (Mellaril) o Caffeine (Viviran, Cafcit) o Pentobarbital (Nembutal) o Ephedrine (Bronkaid) o Thiothixene (Navane) o Secobarbital (Seconal) o Ziprasidone (Geodon) o Guanfacine (Tenex, Intuniv) ☐ 14. DIRECT BIOMARKERS ☐ 17. CARDIOVASCULAR (cont’d) ☐ 21. DIABETIC o Cotinine (Nicotine) o Eletriptan (Relpax) o Glimepiride (Amaryl) o ETG (Ethanol Metabolite) o Enalaprilat (Vasotec, Renitec) o Glipizide (Glucotrol) o ETS (Ethanol Metabolite) o Ezetimibe (Zetia, Ezetrol) o Glyburide (Glynase) o Fenofibrate (Tricor) o Linagliptin (Tradjenta) o Flecainide (Tambocor) o Metformin (Glumetza) 15. ANTI-INFLAMMATORY / NSAIDs ☐ o Gemfibrozil (Lopid) o Nateglinide (Starlix) o Allopurinol (Aloprim) o Hydrochlorothiazide (Microzide) o Pioglitazone (Actos) o Celecoxib (Celebrex) o Irbesartan (Avapro) o Repaglinide (Prandin) o Chlorpheniramine (Chlor Trimenton) o Labetalol (Normodyne) o Rosiglitazone (Avandia) o Colchicine (Colcrys,Mitigare) o Lisinopril (Prinivil) o Saxagliptin (Onglyza) o Diclofenac (Voltaren, Cambia, Solaraze) o Losartan (Cozaar) o Sitagliptin (Januvia) o Etodolac (Lodine) o Metoprolol (Lopressor) o Febuxostat (Uloric) o Nadolol (Corgard) ☐ 22. DIURETICS / INCONTINENCE o Hydroxychloroquine (Plaquenil) o Nifedipine (Adalat) o Acetazolamide (Daimox Sequels) o Ibuprofen (Advil) o Olmesartan (Benicar) o Alfuzosin (Uroxatral) o Indomethacin (Tivorbex) o Pentoxifylline (Pentoxil) o Canrenone (Contaren) o Meloxicam (Mobic) o Propranolol (Inderal) o Chlorothiazide (Diuril) o Naproxen (Aleve, Naprosyn) o Ranolazine (Ranexa) o Darifenacin (Enablex) o Olopatadine (Patanol, Pataday) o Rivaroxaban (Xarelto) o Doxazosin (Cardura) o Oxipurinol (Oxyprim) o Simvastatin (Zocor) o Furosemide (Lasix) o Piroxicam (Feldene) o Telmisartan (Micardis) o Indapamide (Losol) o Sumatriptan (Alsuma) o Ticagrelor (Brilinta) o Solifenacin (VESIcare) o Tofacitinib (Xeljanz, Jakvinus) o Valsartan (Diovan) o Terazosin (Hytrin) o Verapamil (Verelan) o Torsemide (Demadex) 16. ANTI-HISTAMINES o Warfarin (Coumadin) ☐ o Triamterene (Dyrenium) o Cetirizine (Zyrtec) o Desloratadine (Clarinex) ☐ 18.ANTIMICROBIAL ☐ 23. PDE (Phosphodiesterase inhibitors) o Diphenhydramine (Benadryl, Banophen) o Itraconazole (Sporanox) o Sildenafil (Viagra, Revatio) o Fexofenadine (Aller-ease) o Nitrofurantoin (Macrobid) o Vardenafil (Levitra) o Hydroxyzine (Vistaril) o Loratadine (Claritin) o Tadalafil (Cialis, Adcirca) o Montelukast (Singulair) ☐ 19. GASTROINTESTINAL / DIETARY o Biotin (Vitamin B7/H) ☐ 24. CORTICOSTEROIDS / HORMONE o Famotidine (Pepcid) THERAPY ☐ 17. CARDIOVASCULAR o Hyoscyamine (Levsin) o Budesonide (Entocort) o Acebutolol (Sectral) o Lansoprazole (Prevacid) o Dexamethasone (Ozurdex) o Amiodarone (Nexterone, Pacerone) o Metoclopramide (Reglan) o Levothryoxine (Synthroid) o Amlodipine (Norvasc) o Omeprazole (Losec, Prilosec) o Finasteride (Proscar) o Apixaban (Eliquis) o Pantoprazole (Protonix) o Prednisolone (Omnipred) o Atenolol (Tenormin) o Ranitidine (Zantac) o Raloxifene (Evista) o Atorvastatin (Lipitor) o Benazepril (Lotensin) ☐ 20. ANTI-EMETIC o Bisoprolol (Zebeta, Concor) ☐ 25. ANTI-NEOPLASTICS / CANCER THERAPY o Ondansetron (Zofran) o Candesartan cilexetil (Biopress, Atacand) o Methotrexate (Trexall) o Promethazine (Phenergan, Phenadox) o Candesartan (Biopress, Atacand) o Carvedilol (Coreg) o Cilostazol (Pletaal) ☐ 26. DEMENTIA (Parkinson’s/Alzheimer’s) o Clopidogrel (Plavix) o Donepezil (Aricept) o Dabigatran (Pradaxa) o Rivastigmine (Exelon) o Diltiazem (Cardizem) o Ropinirole (Requip) o Dipyridamole (Persantine) o Dronedarone (Multaq) 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. Minimum of 5 mL specimen provided in Urine Test Cup (seal lid!) Collected by: ___________________________________________ or Minimum of 0.25 mL specimen provided in Oral Fluid Device Urine/Saliva device sealed tightly & bagged in BIOHAZARD BAG with no spill or CleanAssure™ test by dried blood spot (use 4-tip Microsampling Kit). 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_URI_OF-COMPREHENSIVE-001 Rev 5. 03/2020 COPYRIGHT © – ALCALA LABS Page 2 of 2 .