Fill out the Physician Directed Profile Form below. A copy will be automatically sent to Qitek Labs. Prefer to fill out a paper copy? Click here. Physician Directed Profile Account InformationAccount Name*Phone*FaxEmail* Address*City*State*Zip Code*Contact Name*Title*Physician Directed ProfileQualitative/Presumptive TestingQualitative/Presumptive Panel* Antidepressants, Barbiturates, Benzodiazepines, Illicits, Marijuana, Opioids, Opiates, Stimulants Quantitative/Confirmation TestingComprehensive All Drug Classes Below will be Tested Alcohol Select All Ethyl Glucuronide Ethyl Sulfate Benzodiazepines Select All Clonazepam 7-aminoclonazepam Alprazolam a-Hydroxyalprazolam Lorazepam Nordiazepam Oxazepam Temazepam Diazepam Zolpidem Carboxyzolpidem Opiates Select All 6-MAM Codeine Hydromorphone Hydrocodone Morphine Oxycodone Oxymorphone Propoxyphene Norpropoxyphene Muscle Relaxers Select All Cyclobenzaprine Carisoprodol Meprobamate Antidepressants Select All Amitriptyline Nortriptyline Desipramine Imipramine Fluoxetine Duloxetine Venlafaxine Doxepin Desmethyldoxepin Desmethylvenlafaxine Paroxetine Sertraline Illicits Select All Benzoylecgonine PCP Methamphetamine MDMA MDA Opioids Select All Methadone EDDP Buprenorphine Norbuprenorphine Fentanyl Norfentanyl Tapentadol N-Desmethyltapentadol Tramadol O-Desmethyltramadol Opioid Antagonists Select All Naloxone Naltrexone Barbiturates Select All Butalbital Phenobarbital Miscellaneous Select All THC-COOH Cotinine Stimulants Select All Amphetamine Methylphenidate Ritalinic Acid Weight Loss Select All Phentermine Anticonvulsants Select All Gabapentin Pregabalin Physician AuthorizationI hereby authorize Qitek Labs to utilize the above panel as a custom Physician Directed Panel when performing any toxicology qualitative/quantitative testing for this account and location.Physician Name (Last, First)*NPI #*MD/DO/DC PA/ARNP*Signature*Date* Date Format: MM slash DD slash YYYY
