The Carlson Company LLC

10343 Federal Blvd. Suite J- 401,Westminster, CO 80260

Request for Toxicology/DNA Lab Testing Services for Physical Samples
Private Test Submission Form

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Sample Donor's Name

Print ____________________________________________________________________________________ Age _________

Is the sample donor deceased? Yes ________   No _________

Address ______________________________________________________________________________________________

City _______________________________ State ____________ Zip Code __________________ Phone __________________

Email _________________________________________________________________________________________________

Incident

Suspected Incident Date ______ /_____ /______ *

Sample Collection Date ______ /_____ /________

Sample Submission Date _____ /_____ /________

Please note: If you submit hair strands for evaluation we require that you make a testing sample choice. The choices are:

Test and evaluate the hair sample segments based on the above incident date or test full length hair strands. Circle one

Sample/Case Scenario

Test sample (s) description ______________________________________________________________________________

Brief scenario about this case _____________________________________________________________________________

______________________________________________________________________________________________________

Sample Submitter

I certify that I am submitting this test sample (s) (circle your choice) on my own behalf or on behalf of the identified sample donor shown above.

If the donor and submitter are the same person write in, "same as donor" in the sample submitter name line below.

Sample submitter's name (print) ___________________________________________________________________________

Signature _____________________________________________________________________________________ Date ___________________

Address ______________________________________________________________________________________________

City _______________________________ State ____________ Zip Code__________________ Phone __________________

Email _________________________________________________________________________________________________

Requested Testing Choices

Please test the submitted sample (s) for: circle your choice (each circled testing choice requires a corresponding testing fee) 

Unknown chemicals and other toxins | Unknown drug scan | Infidelity (semen detection) | Infidelity (presence of a woman DNA)  

e, g DNA saliva, skin cells. |Infidelity (lipstick/cosmetics, make up, etc.) | 37 date rape drugs | Date Drug DFSA Synthetics| Five (5) panel drug | Ten (10) panel drug 

Basic heavy metals | Complete heavy metals | Antifreeze | Cremains | Drugs- Prescription- Non Prescription.  

Analytical verification of contents (identify sample components). 

Other

(explain)________________________________________________________________________________________________

_____________________________________________

Unique test or sample? Please call 1-866-889-3410 (toll free seven days a week) if you need assistance.

If applicable (not required for DNA, cremains, or infidelity testing) list specific prescription or non-prescription drugs formerly or currently being taken by the sample donor over the past six(6)months_________________________________________________________________________