The Carlson Company LLC

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

REQUEST for TOXICOLOGY/DNA LAB TESTING SERVICES for PHYSICAL SAMPLES WITH STRICT CHAIN of CUSTODY SAMPLE SUBMISSION

Print This Form

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_________________________________________________________________________

_____________________________________________________________________________________________________

Witness or Witnesses to the Sample Collection

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.

Witness #1 to the sample collection  

Name (print) ____________________________________________________________________________________________

Signature _______________________________________________________________________________________________

Date _____ /______ /______

Email ___________________________________________________________________________________________________

Phone _____________________________________

Witness #2 to the sample collection  

Name (print) _____________________________________________________________________________________________

Signature ________________________________________________________________________________________________

Date _____ /______ /______

Email ___________________________________________________________________________________________________

Phone _____________________________________

Certified test report return options 

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 ______

Office use only

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 ______ /______ /______