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Services Requested

DOTNON-DOT
Nursing Physical (Fit for Duty Physical)Basic PhysicalIntermediate PhysicalComprehensive Physical

Workers' Compensation

Yes, I do want this service.


Drug Screening:

This section hereby authorizes Low Country Drug Screening, LLC to disclose test results for specimens by employees or applicant.

Primary Designated Employer Representative (DER)

If Primary Designated Employer Representative is not available -


Low Country Drug Screening sets up and submits results through a secure database called Sharefile. Please provide the names and email addresses for those who should be able to access and receive results through Sharefile


Billing/Mailing Address



Other Info


If you would like someone to contact you regarding the information you submitted on this form please check the box below:



Low Country Drug Screening, LLC shall be permitted to send test results by telephone, telecopier or other electronic service upon request. I understand that Low Country Drug Screening, LLC will not release test results or other confidential information to anyone other than the representatives above agrees to hold Low Country Drug Screening, LLC or any of it's agents harmless from any action that may arise out of such test results being divulged to any of the individuals listed above. I agree to contact Low Country Drug Screening, LLC. if there are any changes regarding this authorization.