Laserfiche WebLink
<br />e <br /> <br />e <br /> <br />DISCLOSURE OF MEDICATION AND INGESTED SUBSTANCES; <br /> <br />I understand that the drug test results pertaining to the <br />analysis of a urine specimen I am about to voluntarily give <br />can be affected by prescription medication, non,prescription <br />medication, and some chemical and food substances such as <br />poppy seeds. <br /> <br />I now wish to take this opportunity to identify any <br />substances that could affect the proper analysis of my urine <br />specimen. <br /> <br />In the past 30 days, I have taken the following named <br />prescription or non-prescription medications: <br /> <br />The above medications were taken in order to treat: <br /> <br />[] Pain [] Muscle spasms [] Allergies [] Nervousness <br />[] Nausea, vomiting, diarrhea [] Asthma, wheezing <br />[] Coughing, sneezing, congestion [] Heart problems <br />[] Weight problems [] Sleeping problems [] Depression <br />[] Other <br /> <br />In the past 5 days, I have ingested the following chemical <br />or food substances: <br /> <br />At this time I am not aware of any medications or other <br />substances that may be in my body system which would affect <br />the drug test I am about to take. <br /> <br />(Date) <br /> <br />(Signature) <br />