toxicology.abbott UK – Family Law Request For Quotation

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1. Donor Information

Donor's Name*

Date of Birth

Day

Month

Year

Gender

Male

Female

This field is hidden when viewing the form

Please tick if you are trying to verify results from another laboratory

Yes, I'm trying to verify results

2. Drug Testing Options

Drug Testing Not Required

Sample Type to be Tested

Select either Hair and/or Urine.

Body Hair (overview analysis only)

Head Hair

Urine

Please select either Body Hair or Head Hair - and/or Urine.

Please select the drug groups to be analysed*

Amphetamine and Methamphetamines (inc. Ecstasy)

Benzodiazepines

Cannabis

Cocaine (inc. Crack)

Ketamine

Mephedrone

Methadone

Opiates (inc. Heroin)

Other

Other*

Period and type of drug analysis for hair samples

Number of months the test is to cover*

Type of analysis*

Month-by-month (head hair only)

Overview

Sample Weight (Hair)

I authorise that the laboratory may proceed with the requested testing in the event that the sample does not meet the minimum sample requirement.

3. Chronic Excessive Alcohol Testing Options

Alcohol Testing Not Required

Individual Tests*

Head hair 3 months

Head hair 6 months

Body hair

Phosphatidylethanol (PEth) dried blood spot

Liver Function Test (LFT) and Carbohydrate Deficient Transferrin (CDT) (blood)

Please select either Head hair 3 months or 6 months.

Please select either Head hair 6 months or Body Hair.

Please select either Head hair 3 months or Body Hair.

4. Lead party information / billing address

Contact name*

Organisation*

Address*

Email*

Phone*

Postcode*

Case ref

5. Split Invoicing

Do you require our free split invoicing service?*

Yes

First Additional Party*

Contact/legal name Organisation Address Postcode Tel. no:

Email*

Case ref*

Client name*

Share of invoice (%)*

Second Additional Party

Contact/legal name Organisation Address Postcode Tel. no:

Case ref

Client name

Share of invoice (%)

Third Additional Party

Contact/legal name Organisation Address Postcode Tel. no:

Case ref

Client name

Share of invoice (%)

6. Who is taking the sample?

Please select one option:*

Abbott Collecting Officer

Solicitor/Social Worker (Self-collect)

Collection address or address where kit is to be sent to:

Same as lead party address*

Yes

Contact Name

Organisation

Address

Postcode

Telephone Number

Residential address of donor*

Yes

Desired collection date (if applicable)

Day

Month

Year

Desired collection time (times available between 10:00 – 16:00)

Hours

Minutes

7. Results

Is an expert witness report for hair testing required?*

Yes

For which court?

Civil

Family

If blank, the report will be written for the family court.

Customer results information – sent via secure email:

Same as lead party address*

Yes

Contact Name*

Organisation*

Email*

Telephone Number*

Court Date

Day

Month

Year

(if applicable)

Please detail any additional information below:

If you wish to receive marketing via email please tick here:

Yes

Phone

This field is for validation purposes and should be left unchanged.