DT Form 2

Republic of the Philippines

Province of __________________
Municipality of _____________________

CONSENT FORM

________________________________ ___________________________ _______________________ ________

FAMILY NAME FIRST NAME MIDDLE NAME AGE

Have you taken medicines/drugs in the past 30 days? _______ ( YES) _________ (NO)
Have you ingested any alcohol beverages in the past 24 hours? _______ (YES) ________(NO)
If you are taking medications/any drug, pls. list these items below.

_____________________________ ____________________________________ ____________________________________

_____________________________ ____________________________________ ____________________________________

I hereby give my consent and agree to give sample of my urine to be used for testing of my urine for
illegal/dangerous drugs. I hereby acknowledge that the urine sample is my own and that this sample
was sealed in my presence.
.

__________________________________________ _________________________
Signature over Printed Name of Client Date

DT Form 2

Republic of the Philippines

Province of __________________
Municipality of _____________________

CONSENT FORM

________________________________ ___________________________ _______________________ ________

FAMILY NAME FIRST NAME MIDDLE NAME AGE

Have you taken medicines/drugs in the past 30 days? _______ ( YES) _________ (NO)
Have you ingested any alcohol beverages in the past 24 hours? _______ (YES) ________(NO)
If you are taking medications/any drug, pls. list these items below.

_____________________________ ____________________________________ ____________________________________

_____________________________ ____________________________________ ____________________________________

I hereby give my consent and agree to give sample of my urine to be used for testing of my urine for
illegal/dangerous drugs. I hereby acknowledge that the urine sample is my own and that this sample
was sealed in my presence.

_______________________________________________ _________________________
Signature over Printed Name of Client Date