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DONOR INFORMATION
Full Name:
Male Female Date of birth:
Address:
Postcode:
Landline Telephone:Mobile Telephone:
DRUG TESTING
Substances to be tested Please contact us if you require testing for any other drugs
Amphetamines (incl. Methamphetamine and Ecstasy) / Opiates (incl. Heroin metabolite) / Tramadol
Benzodiazepines / Ketamine / Synthetic Cannabinoids (Spice)*
Cannabis / Buprenorphine / New Psychoactive Substances*
Cocaine (incl. Crack) / Mephedrone*
Methadone / Steroids* / * longer turnaround time
Sample type
Head Hair / Body Hair / Urine / Oral Fluid
For head hair testing only(Body hair only provides a 12 month overview. Note: if sufficient head hair is not available sampler may at their discretion sample what hair is available. )
Number of months to be tested:
Show results as overview Month-by-month analysis Other i.e. segments, each of months
ALCOHOL TESTING
Alcohol testing suite Recommended by our Scientists as a more comprehensive indication of chronic alcohol misuse
Blood and head hair sample, includes Carbohydrate Deficient Transferrin (CDT)*, Liver Function Tests (LFTs), Ethylglucuronide (EtG) and Fatty Acid Ethyl Esters (FAEE)
*CDT is subcontracted – turnaround time not affected / 3 month overview
6 month overview
Is there a risk of blood-borne infections that we should be aware of when collecting blood samples? Yes No
Alcohol test only
Head hair sample, includes Ethlyglucuronide (EtG) and Fatty Acid Ethyl Esters (FAEE) / 3 month overview
6 month overview
REPORTING AND INVOICING
Method of results delivery: Email only Post only Email and post
Reports are issued 5 working days from receipt of samples. Additional reports are available and will be charged at £15.00 + VAT
Expert Witness Report This is an optional service and will be charged at £120.00 + VAT
Family Court Civil Court Criminal Court Not Required
Purchase order number If you require split invoicing, please give details on page 3
ANY FURTHER INSTRUCTIONS
INSTRUCTING PARTY INFORMATION
Note: The instructing party ordering the test will be presumed to be the Nominated Person to whom results will be issued at the first instance. If Test Report is to be issued to someone else, please provide details separately.
Full Name:
Position:
Company Name:
Address:
Postcode:
Landline Telephone:Mobile Telephone:
Email:
Fax:
Court Date:Court Reference:
Your Reference Number:
DECLARATION
I/we have been authorised by the Courts to instruct Anglia DNA Servicesto carry out drug and alcohol testing analysis required in relation to the named Donor (stated overleaf). I/We have read Anglia DNA’s Code of Practice and Service Level Agreement and I/we accept Anglia DNA’s Terms and Conditions which are incorporated into this contract and accept responsibility for Anglia DNA’s fees.
SIGNED (Instructing Party)Date:
Thank you for completing this Quote/Order Form. Please call 01603 358 161 to speak with a member of our Client Services Team if you wish to discuss your requirements further, we will be happy to assist you.
Please return this completed form to:
Anglia DNA Services, 33 Scottow Enterprise Park, Lamas Road, Badersfield, Norwich NR10 5FB
Tel: 01603 358 161 / fax: 01603 298 071 / email: / web:
Is this participantpart of a case that requires legal DNA testing?
If so, please tell us as we may be able to offer you combined sampling and a 10% discount.
PLEASE INDICATE IF YOU REQUIRE SPLIT INVOICING BY ENTERING DETAILS BELOW
Please note if the invoice is to be issued to a different department for processing please give details below
Invoice F.A.O Full Name:Representing (Name):
Department:
Address (if different from Instructing Party):
Postcode:
First Party Details
Full Name:Representing (Name):
Company Name:
Address:
Postcode:
Landline Telephone:Mobile Telephone:
Email:Fax:
Second Party Details
Full Name:Representing (Name):
Company Name:
Address:
Postcode:
Landline Telephone:Mobile Telephone:
Email:Fax:
Third Party Details
Full Name:Representing (Name):
Company Name:
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Fourth Party Details
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©Anglia DNA Services Page 1 of 3[CORDER/15/13.10.17/BB/RC]
IDna Genetics Limited T/A Anglia DNA Services 33 Scottow Enterprise Park, Lamas Road, Badersfield, Norwich NR10 5FB
T: +44 (0)1603 358161 F: +44 (0)1603 298071 E: W:
Registered office: Centrum, Norwich Research Park, Colney Lane, Norwich NR4 7UG Registered in England and Wales No. 05061695