Toxicology Specimen Subject Consent Form

SUBJECT CONSENT FORM THE STATE OF TEXAS VS. (Subject Name) Be it remembered that on this day of , 20 , I , having been placed under arrest on a (Subject Name) charge of driving a motor vehicle on a public highway while intoxicated, do voluntarily give a specimen of my blood/urine to . (Arresting Officer) Subject’s Signature: Subject Address: Collection Witness: (Print Name and Signature)

Retain for Customer Record. Do Not Send to Laboratory.