ePassport™

*AI********D**

AI********D*

For Clinic Use:

Clinic Information:

Concentra Medical Center - Airport Phoenix

**** * *** ****** *** N

STE 150

PHOENIX,AZ 85034

ph #:602-***-****

DON'T FORGET!

- Take ePassport and Photo ID

- All other documents provided

- Call clinic to confirm their hours of service

*Use eScreen Scheduled Event Account*

Scan the ePassport barcode into eScreen123.

Confirmation #: AI85212858D2 Scheduled Event Details will appear. Services to be performed:

Name: Joey Moreno

Donor ID:

eScreen Acct #: 103180-1

FedEx Express

Additional Requirements/Notes:

Scheduling Manager Name:Lynne Simmons Scheduling Manager Phone:602-***-**** Bill services to :

eScreen, Inc.

PO Box 25902

Overland Park, KS 66225

Contact eScreen Client Services with questions: 800-***-**** opt. 5 Proceed immediately to collection site.

Regulation: NON-DOT

Reason for Test: Pre-employment

Do Not Use eCup

Fax: 602-***-****

Clinics with eScreen123 must scan passport into eScreen123. Complete all services. Urine Collection - 30C7 - HHS DOT Mirror (30C7) Additional Fees

Contact this candidate