10343 Federal Blvd. Suite J- 401,Westminster, CO 80260
Print ____________________________________________________________________________________ Age _________
Is the sample donor deceased? Yes ________ No _________
Address ______________________________________________________________________________________________
City _______________________________ State ____________ Zip Code __________________ Phone __________________
Email _________________________________________________________________________________________________
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
Test sample (s) description ______________________________________________________________________________
Brief scenario about this case _____________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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 _________________________________________________________________________________________________
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_________________________________________________________________________
_____________________________________________________________________________________________________
The witness or witnesses (at least one is required) to the sample collection should sign below. I, as a witness to the sample collection, confirm the identity of the sample donor and
sample description as stated above. I certify that the test sample (s) being submitted represents an "as collected" sample. I did or did not (circle one) assist with the sample
collection from the donor. I (witnessed) the said sample (s) being placed in an envelope or other suitable container for shipping and then sealed the envelope or container with a piece of tape.
I then printed my name and the current date and time on the sealing tape to originate Chain of Custody. The sealed sample envelope or container was then surrendered
to (circle one) USPS - UPS ? FEDEX for shipping to The Carlson Company LLC.
Name (print) ____________________________________________________________________________________________
Signature _______________________________________________________________________________________________
Date _____ /______ /______
Email ___________________________________________________________________________________________________
Phone _____________________________________
Name (print) _____________________________________________________________________________________________
Signature ________________________________________________________________________________________________
Date _____ /______ /______
Email ___________________________________________________________________________________________________
Phone _____________________________________
Lab reports are returned to our clients by email, no additional charge. Please return my test report by email _____
If you wish to have your test report (s) returned to you by the USPS please include a S.A.S.E. with your sample submission.
If you reside in the contiguous United States and prefer to receive your report by UPS or FedEx Ground Services please add an
additional $20.00 dollars to your testing fee.
If you reside outside the contiguous United States international shipping fees will apply.
Return my test report by UPS International Air Service ______
Sample (s) received by The Carlson Company LLC from the sample submitter via - USPS - UPS - FEDEX
Date ______ /______ /______
Sample released to _______________________________________________via - USPS - UPS - FEDEX
Date ______ /______ /______
Sample received by _______________________________________________ via - USPS - UPS - FEDEX
Date ______ /______ /______
Sample released to ________________________________________________via - USPS - UPS - FEDEX
Date ______ /______ /______
Sample received by _______________________________________________ via - USPS - UPS - FEDEX
Date ______ /______ /______
