Please complete our Intake Form below so that we may begin your service.

CONTACT INFORMATION

FIRST NAME *

MIDDLE NAME

LAST NAME *

ADDRESS *

CITY *

STATE *

ZIP CODE *

PHONE *

ALTERNATIVE PHONE

EMAIL *

DATE OF BIRTH *

LAST 4 DIGITS OF YOUR SOCIAL/ITIN *

RACE *

WHAT IS OTHER *

WHAT WAS YOUR GENDER AT BIRTH *

MALE
FEMALE

BELOW UPLOAD A COPY OF YOUR: State ID, Driver's License, Passport, Military ID, Student ID or Employee ID *

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HOW WOULD YOU LIKE TO RECIEVE YOUR RESULTS *

EMAIL
MAILED
PHONE CALL
TEXT
SAME DAY PRINT OUT
FAXED
PICK UP AFTER SERVICE
OTHER

WHAT IS OTHER *

DO YOU HAVE AN APPOINTMENT *

YES
NO I am a Walk In

WHAT TYPE OF TEST OR SERVICE WILL YOU BE GETTING TODAY (Select as many as needed.) *

DEPARTMENT OF TRANSPORTATION TEST
DRUG TEST
ALCOHOL TEST
DRUG + ALCOHOL TEST
DNA TEST
WELLNESS TEST
FITNESS TEST
BACKGROUND CHECK
NOTARY
APOSTILLE
FINGERPRINT
OTHER

WHAT IS OTHER *

WHAT TYPE OF HEALTH + WELLNESS TEST WILL YOU BE GETTING (Select as many as needed.) *

Allergy Test
Chlamydia + Gonorrhea Test
COVID 19 Test
Diabetes Screening
Hepatitis B Test
Hepatitis Panel Screening
Herpes Test
HIV + AIDS Test
Immigration Health Screening
Lead Test
Lyme Disease Screening
Measles Mumps and Rubella (MMR) Test
Measles Titer Test
Men's Fertility Test
Mold Test
Ova + Parasite Test
Parasite (Malaria) Test
Pet Allergy Test
Post COVID 19 Test
Pregnancy Test
Sickle Cell Screening
STD Screening
Steroid Test
Student Health Screening
Toxic Heavy Metal Screening
Tuberculosis (TB) Skin Test
Women's Fertility Test

BELOW UPLOAD A COPY OF YOUR Commercial Driver's License (CDL) *

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WHAT TYPE OF DNA TEST WILL YOU BE GETTING *

WHAT IS THE NAME OF THE OTHER DONOR *

WHAT IS THE NAME(S) AND AGE(S) OF THE OTHER DONOR(S) *

WHAT IS THE OTHER DONOR RELATIONSHIP TO YOU *

WHERE IS THE OTHER DONOR LOCATED (CITY, COUNTRY) *

WHAT TYPE OF ANIMAL WITH BE GETTING TESTED *

WHERE IS THE ANIMAL CURRENT LOCATED *

WHAT IS THE NAME(S) AND AGE(S) OF THE CHILD(REN) DONOR(S) *

WHEN IS YOUR DUE DATE *

WHAT IS THE NAME OF THE OTHER DONOR *

IS THE CHILD A MINOR *

WHAT IS THE NAME OF THE OTHER ADULT DONOR *

WHAT IS THE CHILD DONOR'S FULL NAME *

LAST 4 DIGITS OF THEIR SOCIAL/ITIN *

DATE OF BIRTH *

WHAT WAS THEIR GENDER AT BIRTH *

MALE
FEMALE

RACE *

WHAT IS OTHER *

BELOW UPLOAD A COPY OF THEIR BIRTH CERTIFICATE *

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WHAT IS THE CHILD DONOR'S FULL NAME *

LAST 4 DIGITS OF THEIR SOCIAL/ITIN *

DATE OF BIRTH *

WHAT WAS THEIR GENDER AT BIRTH *

MALE
FEMALE

RACE *

WHAT IS OTHER *

BELOW UPLOAD A COPY OF THEIR BIRTH CERTIFICATE *

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Supported format: JPG, JPEG, PNG, PDF, DOC, HEIC

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WHAT IS THE NAME OF THE OTHER ADULT DONOR *

IS THERE AN ADDITIONAL CHILD THAT WILL BE TEST *

WHAT IS THE CHILD DONOR'S FULL NAME *

LAST 4 DIGITS OF THEIR SOCIAL/ITIN *

DATE OF BIRTH *

WHAT WAS THEIR GENDER AT BIRTH *

MALE
FEMALE

RACE *

WHAT IS OTHER *

BELOW UPLOAD A COPY OF THEIR BIRTH CERTIFICATE *

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Supported format: JPG, JPEG, PNG, PDF, DOC, HEIC

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WHAT IS THE NAME OF THE OTHER ADULT DONOR *

WHAT ARE THE NAMES OF THE OTHER DONORS *

WHEN IS YOUR DUE DATE *

WHAT IS THE NAME OF THE OTHER ADULT DONOR *

DO YOUR DOCUMENTS REQUIRE WITNESSES *

DO YOU HAVE YOUR OWN WITNESSES *

DO YOUR DOCUMENTS NEED TO BE TRANSLATED *

HAVE YOU HAD A BLOOD TRANSFUSION IN THE LAST 3 MONTHS *

HAVE YOU EVER HAD A BONE MARROW OR STEM CELL TRANSPLANT *

PLEASE LIST ANY PRESCRIBED MEDICATION YOU ARE CURRENTLY TAKING

YOUR SERVICE IS BEING ADMINISTERED FOR *

Employment
Government Request
Personal
Post Accident
Other

WHAT TYPE OF EMPLOYMENT PHYSICAL WILL YOU BE GETTING (Select as many as needed.) *

WHAT IS OTHER *

PAYMENT FOR THE TODAY'S SERVICE WILL BE COMPLETED BY *

You
Employer
Government Account
Pre-Payment
Other

WHAT IS OTHER *

HIPAA RELEASE + AUTHORIZATION

I understand authorization is not required for disclosures related to treatment, payment, health care operations or as may be otherwise authorized by law. And that One Lane Living uses this form and other forms that complies with HIPAA and other applicable laws. *

I confirm that I am the legal guardian/representative of the minor(s)/individual participating in services performed by One Lane Living and have the legal ability to proceed or revoke access of said minor(s)/individual service information retained by One Lane Living to third parties at my discretion. *

YES
NO
NOT APPLICABLE

I further understand individuals cannot be denied treatment based on a failure to complete this authorization form. *

I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to One Lane Living and that this agreement expires one (1) year from the time this authorization is confirmed. *

PLEASE SELECT WHAT INFORMATION MAY BE DISCLOSED:

All Health Information
Billing Information
Consultation Reports
Diagnostic Test Reports
Discharge Summary
Drug, Alcohol or Substance Records
Genetic Information
Physical Exam
Lab Results
Operation Reports
Past/Present Medications
Pathology Reports
Patient Allergies
Physician’s Orders
Progress Notes
STD, HIV, AIDS Test Results/Treatments

I do not consent to the disclosure of services provided by One Lane Living to any third party except for entities authorized by law.

Click Here To Agree With This Statement

I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. *

I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected. *

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws. *

I have read this form and agree to the uses and disclosures of the information as described. *

By entering my full name below I confirm that I have reviewed all information within this HIPAA Release + Authorization and approve all statements created by me. *

DATE *

TERMS + ACKNOWLEDGEMENT

- I have been informed and I understand that my agreement to submit to a One Lane Living test is completely voluntary on my part and that I have the right to refuse to submit to the test(s). *

- I understand that if a Medical Review Officer (MRO) (and/or the MRO agent and/or staff) or Drug Testing Coordinator (DTC) calls me in reference to my test results I should call them back immediately if the call was unsuccessful. I understand that if I do not contact and talk with the MRO (and/or the MRO agent and/or staff) then I have turned down the opportunity to discuss the results and the MRO (and/or the MRO agent and/or staff) will report my test as a positive. *

- I have been informed and am aware that the results of the test(s) are protected by confidentiality requirements under Federal laws and regulations. Therefore, I voluntarily agree to the release of the test results. *

- I authorize the MRO (and/or the MRO agent and/or staff) and the DTC who will receive the results of my test to disclose the results of the test(s) to the appropriate Human Resource Director, supervisor, Administrative Body over me, government entity and/or their designee. *

- I understand that the MRO (and/or the MRO staff) may inform the Human Resource Director, supervisor, Administrative Body over me, government entity and/or their designee of any legally obtained prescription medication I may be taking. *

- I understand I have presented my official identification. *

- I understand urine samples will be analyzed for temperature, specific gravity, Creatinine or other chemical markers to ensure a valid specimen. *

- I have been informed that drinking excessive amounts of fluids can result in a diluted urine sample. *

- I understand that my urine sample will be tested to ensure the urine is not diluted. *

- I authorize One Lane Living, or its agents, to collect biological specimens and perform DNA testing with my specimen or that of the minor or incapacitated individual(s) named on this form. *

- I understand that the biological specimens will be used for genetic testing and may be stored for future testing. *

- I witnessed the labeling of my name and/or individual's name I am consenting for on the cup, envelope, tube or package containing the specimen. *

- I understand, acknowledge and agree that One Lane Living's liability to me arising out of or in any way related to the provision of testing services contemplated herein shall not exceed the cost of the test. *

- I agree to indemnify, defend, and hold One Lane Living, its officers, agents, employees, representatives and any persons or entities collecting specimens harmless from all further claims or damages. *

- I certify that I provided my specimen to the collector, that the specimen container was sealed with a tamper proof seal in my presence and that the information provided on this form and on the label affixed to the specimen container is correct. *

- I certify that the information I have provided is correct and the biological sample that I am submitting is my own. I voluntarily or by court order submit to having a biological sample collected from me, or my child which will be used for analysis. *

- I realize that this procedure is being done at the request of my legal advisor, physician, or upon order of the court and I grant permission to release the results of the test to my legal advisor and other representing agencies. *

- I understand that this confidential information is provided in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited without the prior written authorization of the patient/authorized representative to who it pertains unless otherwise permitted by law. *

- I furthermore limit any claim I may have against One Lane Living, its affiliates or members or shareholders to the monetary cost of the test reduced by any cost One Lane Living, incurred to produce the test and agree to pay for any legal fees incurred by One Lane Living, or its affiliates arising from any such claim. *

- I understand if this test involves a person who is a minor or who is otherwise legally incapable of consenting, I attest that I have the legal authority to consent to testing and assume all legal responsibility. *

- I as the authorized parent or guardian of the minor(s) involved in today’s testing I give One Lane Living full authorization to administer all requested and mandatory tests practiced on said minor(s). *

- I the undersigned am providing One Lane Living my consent for an initial background check as well as any subsequent background checks deemed necessary and authorize information to be obtained either in writing or via telephone. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with government and One Lane Living’s guidelines and regulations. *

I agree that by selecting the this box to receive messages related to appointment reminders, status updates, and answers to FAQ’s at the provided number from One Lane Living. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.

By entering my full name below I verify that the information contained on this form is correct and true to the best of my knowledge and consent to the administering of One Lane Living’s testing process. *

DATE *

Collection: SOBRIETY TESTS

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