ePassport #AI19226462C9 .pdf

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ePassportâ„¢

*AI19226462C9*
AI19226462C9

Clinics with eScreen123 must scan passport into eScreen123. Complete all services.

Clinic Information:
MedSpring - Uptown - DFW
2404 McKinney Ave
Dallas,TX 75201
ph #:214-721-0630
Fax: 512-485-7393

DON'T FORGET!
- Take ePassport and Photo ID
- All other documents provided
- Call clinic to confirm their hours of service

Proceed immediately to collection site.
For Clinic Use:

*Use eScreen Scheduled Event Account*

Scan the ePassport barcode into eScreen123.
AI19226462C9
Confirmation #:
Regulation:
NON-DOT
Reason for Test:
Pre-employment

Scheduled Event Details will appear.

Name:

Michael Davis

eScreen Acct #:

101466-10037
Year Up - Dallas/Fort Worth

Account Type:

National Account

Services to be performed:
Do Not Use eCup
Urine Collection - 1204 - 10 PANEL STANDARD (1204)

Additional Requirements/Notes:

Bill services to :
eScreen, Inc.
PO Box 25902
Overland Park, KS 66225

Contact eScreen Client Services with questions: (800) 881-0722 opt. 5


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