Office Kit Ordering

Requestor Information
Company Name:*
Company Code/Account Number:*

Please note, this should be a set of 3-4 characters that can include letters and numerals.
Requestor First Name:*
Phone Number:*
Email*
Shipping Information (No P.O. Boxes)
Please note, Airbills are only available when ordering 25 or 50 blood and urine kits, 2 pack maximum. Quantity sent will be based on the total amount ordered.
Examiner First Name:*
Examiner Last Name:*
Address 1:*
Address 2:
City:*
State:*
Zip Code:*
Is this a new address?*
- Yes
- No
Kit Order
Blood and Urine Kits - Kits Per Case:
Blood and Urine Kits - Total # of Cases:
DBS and Urine Kits - Kits Per Case:
DBS and Urine Kits - Total # of Cases:
Urine Only Kits - Kits Per Case:
Urine Only Kits - Total # of Cases:
Oral Fluid - Kits Per Case:
Oral Fluid - Total # of Cases:
Airbills - # per pack
Airbills - Total # of packs
Shipping Instructions
Special Shipping Instructions:
Method:
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Requestor Information