ONLINE QUOTATION REQUEST

SCRAM Continuous Alcohol Testing

Upon receipt of your completed form, your request will be dealt with immediately and a quotation will be issued to the appropriate parties as instructed.

For assistance in completing the form, please call us on 029 2048 4141
FIELDS MARKED * MUST BE COMPLETED

Your submission contained errors. Please check for unanswered fields below highlighted in red.
GENERAL INFORMATION
Yes No
1. Participant Details - Please complete the details of the person to be tested
Male Female

If the participant works in an environment where they may be exposed to alcohol i.e. a licensed premises or a facility where ethanol is used, the please provide their working hours:

2. Testing Period - Please specify the time period of testing

If a testing period of over 90 days is selected, we may need to service the unit and replace consumable items such as batteries. This may incur an additional charge and you will be notified accordingly.

30 Days 60 Days 90 Days 120 Days

Other:

3. INSTRUCTING PARTY DETAILS – PLEASE INDICATE WHO IS INSTRUCTING THE TESTING
Legal Aid/Publicly Funded Privately Funded
Yes No

If the cost is to be shared between a number of parties we will send a quotation to each for their share and invoice each for their share after the test results are issued. Each party will be required to authorise their quotation before the sample can be collected.
In accordance with the Legal Aid Agency there is no charge for split invoicing

Legal Aid/Publicly Funded Privately Funded

+ Add Party
4. Result Details - Please include details of who will be receiving the results
Yes No

Please note that the results will only be issued to one party and we will only discuss the results or the progress of the analysis with the party that is receiving the results.

5. SCRAM Bracelet Fitting: This will be undertaken by a Lextox Sample Collector only

Please note that a witness (i.e. a solicitor or social worker) must be present at all appointments.

Participants' Home Office/Facility

If the Base Station is installed in an office then the participant will need to visit the office on a weekly basis for the data to be transferred.

If the device is to be fitted in the participants' home, can you confirm whether they have internet access?

Yes No

 

Option 1

Option 2

You will be contacted by Lextox to confirm availability for all necessary appointments.

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