Forms

We are conducting the urine drug screen under our contractual agreement with your employer/future employer, not
under your patients account, therefore you will not be able to obtain a copy of the results without permission granted
from the company that you are checking in under. Your employer or potential employer has asked us to collect a
urine sample to test for drug abuse. In an effort to collect and process the specimen in a legal manner, protecting all
parties involved, Mountain Medical Immediate Care has developed the following procedures:
1. It is required for you to bring this form with you to the clinic as well as photo identification. Collection and/or
testing will not be conducted without photo identification.
2. Since you will be asked to give a urine specimen, please make sure that your bladder is full when you come in.
Please be sure to eat a well balanced meal that includes some type of protein source at least 1.5 hours prior to
arriving at the clinic. Do not drink more than 8 ounces of fluid in the 4 hours prior to your test. Drinking large
quantities of fluid prior to testing may invalidate the specimen and retesting will be necessary.
3. Once you have given the staff member a urine specimen, you will assist him/her in labeling all specimen,
containers. You will be provided with a copy of the Chain of Custody form for your records. Your employer will be
provided with the results and/or a copy of the chain of custody form.