Place Your Order - Viewpoint Screening

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Required Package
The Health Information Technology program at Waukesha County Technical College requires the following services to be performed.
Health Portal:	At the end of the order process, you will have the capability to log in and upload specific documents required by your school for immunization, medical or certification records.
Drug Test:	Lab based 10 panel urinalysis: You will receive an email from Viewpoint Screening after 1 business day once you finish placing your online order regarding your drug test. This email will contain the instructions to have your drug test performed.
Price:	$75.00

I have read, understand and agree to the Viewpoint Screening Disclaimer and Refund Policy.

Applicant Information
First Name^*:
Last Name^*:
Middle Name:
Alias/Maiden Name 1:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 2:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 3:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Social Security Number^*:	- - Please Note: If you have not been issued a valid U.S. SSN then enter all zeros (000-00-0000) instead.
Date of Birth^*:	/ / (mm/dd/yyyy)
Gender^*:	Male Female
Phone Number^*:	(111-111-1111)
E-Mail Address*: ^{Your email address will be your user name to log in. If you have placed a previous order, it is recommended to use the same email address to prevent separate logins. Separate logins will contain separate results / medical documents, and cannot be combined.}	Please make sure you are entering your correct email address. You will be unable to log in or receive communications from Viewpoint Screening if your email address is not valid. Type E-mail address. Re-type E-mail address. Please make sure you are entering your correct email address. You will be unable to log in or receive communications from Viewpoint Screening if your email address is not valid.

Current Residential Address:
Address^*:
City^*:
State or U.S. Territory^*:	For an international address, select "International" and select the foreign Country name below.
Country^*:
Zip Code^*:	ZIP Code Look Up Tool Please Note: If you have an international address that does not require a Zip Code, please fill in "00000".

First Name^*:
Last Name^*:
Credit Card Number^*:
Exp. Date^*:	(MM/YYYY)
CVV^* ?
Credit Card Type^*:
Contact Name (if business):
Email^*:
Phone Number^*:
Address^*:
City^*:
State^*:
Postal Code^*:
IMPORTANT: Please note that if you enter an address other than the one on file with the credit card's issuing bank, or an incorrect CVV code, Viewpoint Screening will deny your transaction for security purposes. Additionally, denied transactions may cause the funds to be held by your bank for up to 5 business days before being released back to the card. "Viewpoint LLC" will appear on your credit card statement. A Parent or Guardian's credit card will be accepted. WARNING: A non-refundable fee to place this order will be charged to your credit card once you click "Next."

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