ORDER FORM - PLEASE FAX COMPLETED FORM TO

Please
tick box
This form must be completed
and sent back to DNA LEGAL
Request for Quote
All enquiries call - 0203 4243 470
Proceed with Order
ORDER FORM - PLEASE FAX COMPLETED FORM TO 0203 4243 471
Participant Details:
First Name
Middle
Surname Mr / Mrs / Miss / Ms
Address
(Please circle one)
Telephone Email
DOB Invoice & Result Information -
Split invoicing:
Please provide details upon completion of this form.
We require for all parties: name of firm, name of fee earner, relevant reference number, address, telephone and fax numbers.
Main Solicitor
Yes
No
First Name:Surname:Organisation:
Reference:Address:Postcode:
Telephone:Email:
Additional Solicitor/Party
Additional Solicitor/Party
Additional Solicitor/Party
First Name:
First Name:
First Name:
Surname:
Surname:
Surname:
Organisation:
Organisation:
Organisation:
Reference:
Reference:
Reference:
Address:
Address:
Address:
Postcode:
Postcode:
Postcode:
Telephone:
Telephone:
Telephone:
Email:
Email:
Email:
DRUGS TO BE TESTED -
(Please tick as applicable)
Drugs of Abuse Testing Specialist Drugs to be tested
Main 6 Panel Drugs
Legal Highs
Additional 3 Panel
methadone
Cannabis
mephedrone
Cocaine (inc Crack)
(aka methedrone or M-CAT)
Amphetamines
Other Common Drugs
Methamphetamines (inc ecstacy)
Tramadol
Benzodiazepines
Zopiclone
Screen for 186 Drugs including Drugs of
Abuse, Sedatives, Narcotics, Pharmaceuticals,
Epileptics and Neuroleptics.
GHB
S
creen for 36 Bath Salts
Detailed assessment
(designer drugs)
Anabolic Steroids
Screen for all 23 Steroids
Zopidem
Other Drugs (please specify)
compounds inc Spice & K2
Designer Drugs
ketamine
Opiates (inc Heroin)
Detailed Drug Screen
S
ynthetic Cannabis Screen - 24
Other Drugs (please specify)
Individual Steroid detection*
Propoxyphene
Pharmaceutical Screen
Buprenorphone
Screen for over 700 drugs
Individual drug detection*
*Please specify name in space provided
Required Duration of Drug Testing 1 Month (1cm)
3 Month (3cm)
Type of test Required -
(Please tick as applicable)
6 Month (6cm)
9 Month (9cm)
12 Month (approx 12cm)
12 Month (body hair)
(Please tick as applicable)
Standard Test - Average result over approx. 3 month periods (or as far back as the hair allows).
Segmented Test - Provides history of abuse. Length of segment/period
1cm (monthly)
2cm (bi-monthly)
3cm (quarterly)
Body Hair Test - Average result covering approx. 4 - 8 months (no segmentation).
Studies have shown that head hair grows approximately 1cm per month. This growth rate varies slightly (estimated at +/- 0.75cm per month). Standard screening tests cover approximately 90-day periods (3cm); however a more detailed month-by-month analysis can be performed by testing individual 1cm sections
enabling a historic record to be established as far back as the hair sample will allow. Please note that body hair samples cannot be segmented.
© DNA Worldwide Group
Page 1
Order form Drugs - V4 04/14 DL
Drug & Alcohol Testing
ORDER FORM -
PLEASE FAX COMPLETED FORM TO 0203 4243 471
ALCOHOL ABUSE TESTING -
(Please tick as applicable)
It is now possible to assess people who have been drinking heavily or using alcohol regularly (defined as at least 60 grams of alcohol per day) on a routine basis
for a minimum of 2-4 weeks (CDT / LFT) and/or up to six months (ETG/FAEE Test). The combination of blood and hair testing provides a comprehensive report
showing recent and longer term consumption.
Duration of hair Alcohol testing (Please tick as applicable)
0-3cm (approximately covering the previous 3 months)
Test Required -
0-6cm (approximately covering the previous 6 months)
(Please tick as applicable)
SILVER PACKAGE
GOLD PACKAGE
PLATINUM PACKAGE
To determine excessive alcohol abuse for clients who DO NOT bleach, dye or chemically treat their hair
To determine excessive alcohol abuse for clients who
DO chemically treat their hair
To determine Abstinence and/or social drinking vs
excessive alcohol abuse
• Hair Test - EtG
• Blood Test - Carbohydrate-deficient
transferrin (CDT), Liver Function Test (LFT)
& Full Blood Count (FBC)
• Expert Witness statement
• Nurse / Doctor Sample collection
• Hair Test - EtG & FAEE
• Blood Test - CDT, LFT & FBC
• Expert Witness statement
• Nurse / Doctor Sample collection
• Hair Test - EtG & FAEE
• Blood Test - CDT, LFT & FBC
• Extended Expert Witness statement
• Nurse / Doctor Sample collection
Singular Testing if Above Packages not selected -
(Please tick as applicable)
Blood Alcohol Tests:
Carbohydrate Deficient Transferrin (CDT)
Liver Function Test (LFT)
Hair Alcohol Tests:
EtG
Full Blood Count (FBC)
Combined EtG & FAEE
EXPERT WITNESS STATEMENT -
(Please tick as applicable), (automatically included if any alcohol package above chosen)
Expert Witness Statement - DNA Legal include within the testing charges a Certificate of Analysis we can provide an Expert Witness Statement
for court purposes that includes the clarification of the diagnostic findings. One statement covers both Drugs and Alcohol results. DNA Worldwide
strongly recommend that all testing is combined with an expert witness statement.
SAMPLE COLLECTION - SELECT 1 FROM 3 OPTIONS
(Please tick and fill out details as applicable)
(Nurse collection already included if alcohol testing package selected)
The SoHT and courts recommend option 1 to ensure the highest quality sample collection
OPTION 1
Send Nurse to collect sample from
Solicitors Office
Clients Home
OPTION 2
Client will visit one of the DNA Legal
private collection clinics (main cities
only)
OPTION 3
Client to have sample taken at
their GP (not recommended due to
sampling issues)
TO BE COMPETED FOR OPTION 3 ONLY
GP / Visit
GP Name
Middle
Surname Dr / Mr / Mrs / Miss / Ms
Please provide full address of where collection will take place
Please provide full telephone number of where collection will take place (Please circle one)
Postcode
DNA Legal (part of DNA Worldwide Group Ltd)
K10, The Courtyard, Jenson Avenue, Commerce Park, Frome BA11 2FG UK Tel. 0203 4243 470 Email [email protected] www.dnalegal.com
© DNA Worldwide Group
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Order Form Drugs - V4 04/14 DL