Get Started With Butterfield Onsite Drug Testing: Setting Up Protocol

Company Name

Company Phone

Company Email Address

Company Address

Name for Billing

Billing Phone

Billing Email

Billing Address

What is your preferred billing method? What is your preferred billing method?Send through provided EmailSend to physical address

Is a PO or a Job Number Required? Is a PO or a Job Number Required?PO NumberJob NumberBothNot Required

Name of person we report results to:

Phone

Email

Would you like to add additional reporting contacts? Would you like to add additional reporting contacts? Yes No

Name of additional reporting contact

Phone

Email

Would you like to add additional reporting contacts? Would you like to add additional reporting contacts? Yes No

Name of additional reporting contact

Phone

Email

Do you have a company Protocol? Do you have a company Protocol? Yes No Not with a company (Independent Operator) Other Not Sure

Do you have a third-party administrator helping with your Drug & Alcohol program? Do you have a third-party administrator helping with your Drug & Alcohol program? Yes No Consortium I Do It Myself Not Sure Other

Are you with a Union? Are you with a Union? Yes No

Which Union? Which Union? Local 16 - Sheet Metal Local 48 Local 290 Other

Are you interested in Onsite or Clinic Testing? Are you interested in Onsite or Clinic Testing?OnsiteClinicBoth

Reason you are testing? Reason you are testing?Post AccidentFollow-upPre-employmentRandomReasonable SuspicionOther

Are you looking for DOT/Non-DOT Testing? Are you looking for DOT/Non-DOT Testing?DOTNon-DOTPersonalCourt OrderedOther

What type of tests are you looking for? (Select all that apply) What type of tests are you looking for? (Select all that apply) Urine Collection Breath Alcohol Oral Fluid Hair Collection Instant Results Respirator Fit Testing (Qualitative) Respirator Fit Testing (Quantitative) Audiogram (Hearing test) DNA Testing COVID - Antigen Test COVID - Instant Test COVID - PCR Test COVID - Unsure (Please Call) Unsure (Please Call)

Is there a specific drug you want to test for? Is there a specific drug you want to test for? Yes No

Which drug do you want to test for? (Select all that apply) Which drug do you want to test for? (Select all that apply) THC Cocaine PCP AMP Opiates MDMA Barbiturates Benzos Other

How many people are you looking to get test? How many people are you looking to get test?12-34-56-78-1011-1515+ (We will contact you for more details)

When are you looking to schedule? (All appointments will need to be confirmed by office) When are you looking to schedule? (All appointments will need to be confirmed by office)Calendar (Pick a day)ASAPThis week

What day? (Month, Day, Year)

What time of day works best for testing? (Select all that apply) What time of day works best for testing? (Select all that apply) Before 7 AM 7-8 AM 8-9 AM 9-10 AM 10 AM - 12 PM 12-2 PM 2-4 PM 4-6 PM After 6 PM

Are you interested in Reasonable Suspicion or Supervisor Training? Are you interested in Reasonable Suspicion or Supervisor Training?YesNoNot sure - Can I know more?

How did you hear about us? How did you hear about us?LinkedInFacebookInstagramTikTokTwitterReferralOther

Who referred you? (We would love to give them a big thanks!)

Through who or what? (We would love to give them a big thanks!)