Authorize a Service

Clear • Documented • Convenient

Authorize After-Hours or On-Site Services

Use this form when an authorized company representative needs to request and approve MedScreens after-hours or on-site testing services.

Select after-hours or on-site testing and include any important instructions.

Review the terms, complete the representative information and sign the form.

Submitting this form confirms that the representative is authorized by the company to approve the applicable service fees.

Testing Authorization
Date
Company*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please select your testing needs?*
- After Hours for a donor
- On Site Testing
Donor Name:*
First Last
Reason for Test:*
Type of Test:*
Additional Notes or Information:
Authorizing Representative Information:
By completing and signing the information below you are acknowledging you have read and understand our On-Site and After Hours Fee Terms of Service. You also acknowledge that you are authorized by the specified company to approve these fees. Our On-Site and After Hours Fee terms of service may be viewed online
Authorized Representative*
First Last
Phone of Authorized Representative:*
Fax of Authorized Representative:*
Email of Authorized Representative:
Signature
Your Name
Your Name
Your Name

Call MedScreens to confirm availability, timing or service details before submitting the form.