ZCPT S. Jog Rd. Suite Greenacres, FL Phone: (561)

Transcription

1 ZCPT 4300 S. Jog Rd. Suite Greenacres, FL : (561) : ZCPT@ZCLabServices.com Official Use Only Client ID: Toxicology Proficiency Testing Order Form Institution Name (Please Print) CLIA ID Number Name of Laboratory (Please Print) Laboratory Laboratory Fax Medical Director Name (First Last) Medical Director s Ordering Contact Ordering Contact Name (First Last) Medical Director s MD DO PhD Other: Shipping Contact and Address (Used for shipping PT kits) Shipping Contact Name (First Last) Department Name Mailing Contact and Address (Used for Mailing Evaluations and Other Reports) Check here if same as shipping address Shipping Contact Name (First Last) Department Name

2 Order Details See pages 3, 4 and 5 for panel contents. Write quantity in space provided next to panel. Order includes October 2018 and April 2019 testing. X General Panel $2,000 X Designer Drug Panel $1,750 X D/L Methamphetamine Panel $750 X Bundle Package Includes General, Designer and D/L methamphetamine Panels $4,000 (Includes $500 bundle discount) Payment Information Include one of the following options to avoid delay Check this box if orders were paid for online and provide receipt number (located in confirmation ) OR PAYMENT TOTAL (In US Dollars) $ Check Number (Payable to Ziolo Consulting) / Credit Card Number (Visa, MasterCard, Discover or AMEX) Exp Date ( MM/YY) CVC Card Holder Name Card Holder Signature Billing Information Check here if same as Mailing Contact Address Check here if same as Shipping Contact Address Billing Contact Name (First Last) (Required) (Required) (Required) Laboratory Name 2

3 General Panel (-)-Delta-9-THC Fluphenazine HCl Naltrexol,6-B (+) Amphetamine Sulfate Fluvoxamine Maleate Nefazodone HCl (±)-threo-ethylpnenidate HCl Halazepam Nimetazepam 11-Hydroxy-Delta-9-THC (±) Haloperidol Nitrazepam 25I-NBOMe HCl Hydromorphone-3-β-d-glucuronide Norbuprenorphine glucuronide 7-Hydroxymitragynine Hydroxy Desipramine-2 Norcotinine 8-Hydroxyamoxapine Hydroxy-Risperidone (9) Nornicotine 9-Carboxy-11-Nor-Delta-9-THC Hydroxybupropion Norquetiapine HCl glucuronide 9-Carboxy-11-Nor-Delta-9-THC(DL) Iloperidone Oxazepam Glucuronide Acetyl Norfentanyl HCl Ketobemidone Oxcarbazepine Acetylcodeine -6 Levorphanol Tartrate Oxymorphone 3-β-d-glucuronide Alpha-Hydroxymidazolam Lisdexamfetamine dimesylate Phendimetrazine tartrate Alpha-Hydroxytriazolam Loperamide HCl Phenylpropanolamine HCl Amantadine Hydrochloride Lorazepam Glucuronide Pholcodine Aminonitrazepam (7) Lormetazepam Prazepam Amoxapine Lurasidone HCl Propranolol HCl Anabasine m-chlorophenylpiperazine Protriptyline HCl Aprobarbital Maprotiline HCl Pyrazolam Aripiprazole Metabolite (OPC-3373) Meclizine Dihydrochloride Quazepam Asenapine Mephobarbital Ranitidine HCl Atropine Metaxalone Rifampicin Baclofen(±) Methaqualone HCl Risperidone Bromazepam Methedrone HCl Ritalinic Acid Buprenorphine glucuronide Methocarbamol Sufentanil Citrate Buspirone HCl Methyl Norfentanyl -3 Tapentadol-O-sulfate Caffeine Metoclopramide HCl Temazepam Glucuronide Cannabidiol Midazolam HCl Tetrazepam Carfentanil Modafinil Thiopental Chlorpromazine HCl Morphine 3-b-d-Glucuronide H2O Thioridazine HCl Cimetidine Morphine-6-b-d-Glucuronide Tizanidine HCl Clonidine MT-45 Trans-3-Hydroxy Cotinine Codeine-6-b-d-Glucuronide N-Desmethylcitalopram Triamterene Dehydro Aripiprazole N-Desmethylflunitrazepam Triazolam Desmethylvenlafaxine HCl (0) N-Desmethylmirtazapine Trihexyphenidyl HCl Escitalopram Oxalate N-Desmethylolanzapine U Estazolam N-Desmethyltapentadol Warfarin Sodium Ethylmorpine Naloxone-3-ß-D-glucuronide hydrate Zolpidem Phenyl-4-carboxylic Acid Etizolam 3

4 Designer Drug Panel (±)-4-Methylephedrine HCl JWH 018N-(4- m-hydroxybenzoylecgonine hydroxypentyl) 25B NBOMe JWH 018N-(5- MAM-2201 hydroxypentyl) 25C NBOMe JWH 018N-pentanolic acid MAM2201 N-pentanoic acid AB-FUBINACA JWH 019 MBDB HCl - d,l AB-PINACA JWH 019 N-(6-hydroxyhexyl) MDAI HCl AH-7921 JWH 073N-(3-hydroxybutyl) MDPBP HCl AKB48 N-(5-Hydroxypentyl) JWH 073N-(4- Methcathinone HCL (d,l) hydroxybutyl) AM1248 JWH 073N-butanoic acid AM2201 JWH 081 Methcatione HCl (S) AM694 N-(5-Hydroxypentyl) JWH 081N-(5-hydroxypentyl) Mitragynine Anhydroecgonine Methyl Ester JWH 122 Norketamine HCL Buphedrone HCl JWH 122 N-(4- Pentedrone HCl hydroxypentyl) Butorphanol Tartrate JWH 122N-(5-hydroxypentyl) Psilocin Butylone HCl JWH hydroxyindole RCS-4 D,L-Kavain JWH hydroxyindole RCS-4 N-(5-hydroxypentyl) Dehydronorketamine HCl JWH hydroxyindole RCS-4M9 Dextrorphan Tartrate JWH 203 N-(5-hydroxypentyl) RCS-8 Dihydrokavain JWH 210 RCS-8 4-methoxy isomer EMDP JWH 210 N-(4-Hydroxypentyl) TFMPP HCL Fluoromethcathinone HCl (4) JWH 250N-( 4-Hydroxypentyl) UR-144 Gammahydroxybutyric Acid Sodium JWH 250N-(5-hydroxypentyl) UR-144 N-(5-hydroxypentyl) HU-210 JWH 398 W-18 Hydroxy-LSD JWH chlorophenyl isomer XLR-11 (5-Fluoro-UR-144) Hydroxyethylflurazepam (2) JWH-398 N-pentanoic acid XLR11 N-(4-hydroxypentyl) LSD Yangonin 4

5 D/L Methamphetamine Panel d-methamphetamine l-methamphetamine Important Dates 1 st Shipment: October 2018 All October 2018 orders must be received by midnight (PST) Shipping Date: October 29, nd Shipment: April 2019 Shipping Date: April 29,