Drug Test and Medication count form

Point Of Care form

IMPORTANT: Please have the following ready BEFORE you start completing this form:

Driver’s license
Testing supplies
Smart phone

As per our program guidelines, it is time to complete your periodic review tasks requested by your provider. Please follow the instructions below. If you have any questions, please submit a support ticket by going to www.bupe.me, click on or tap on the contact us form and following the instructions.

In this packet you will find everything you need to complete TWO SEPARATE TASKS.

TASK 1: First off, we are going to do a drug screen together. Please follow the instructions you received in the drug screen packet.

TASK 2: Secondly, we are going to upload two separate pictures of your driver license and two-sided drug screen. If you received a 6-Panel drug screen, only one picture is needed with your results.

Provider's Name*

Patient's name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Date of Birth*

Today's date and time *

PICTURE 1: Driver License AND Side One of Drug Screen Test

UPLOAD PICTURE 1: Driver License AND Side One of Drug Screen Test: Upload the picture you took of your driver's license by clicking or tapping the "Choose File" option and selecting the picture you took*

No File Chosen

File uploads may not work on some mobile devices.

PICTURE 2: Driver License AND Side Two of Drug Screen Test

If you received a 6-Panel drug screen, please skip this step

UPLOAD PICTURE 2: Driver License AND Side Two of Drug Screen Test: Upload the picture you took of the testing strip by clicking or tapping the "Choose File" option and selecting the picture you took

No File Chosen

File uploads may not work on some mobile devices.

UPLOAD PICTURE OF YOUR MEDICATION COUNT : Upload the picture you took of your pill count by clicking or tapping the "Choose File" option and selecting the picture you took

No File Chosen

File uploads may not work on some mobile devices.

PATIENT SIGNATURE

Signature of Patient/Responsible Party Signature: By signing below, I certify all information in this document is true and correct to the best of my knowledge.**

[clear]

Use your mouse or finger to draw your signature above