Supply Request List

 * required fields

CLIENT
Email  *
Account Number  *  
Ordered By  *
Company  *
Address  *
City/State/Zip  *

TIME TO ARRIVE AT COLLECTION SITE
Date To Arrive

MORNING  AFTERNOON

SHIP TO
Account Number
Contact
Phone Number
Name
Street Address
City
State
Zip
PLEASE INDICATE QUANTITY- Box or Each
(For Example: 10 Ea or 2 Bxs)
SHIPPING SUPPLIES FOR TOX SPECS

QTY
UPS BAGS
UPS AIRBILLS
DRUG SCREEN COLLECTION KITS

QTY
Single Bottle Kits w/ Box 1176
Single Bottle Kits w/o Box 1178
Split (2-Bottle Kits) w/ Box 1187
Split (2-Bottle Kits) w/o Box 1223
Cord Drug Collection Kit 9735
Rapidease Oral Fluid Collector 1764
Fed Ex Lab Pack 0450
Fed Ex Toxicology Airbill 0451
POCT Drug Screen 6 Panel Test Split w/Adulteration Strip (K) 8355
POCT Drug Screen 10 Panel Test Split w/Adulteration Strip 8354
TAMPER EVIDENT BLUE TAPE 1148
Alco Screen 02 1318
Hair Tox Coll Kit 9733
Meconium Tox Coll Kit for Infants 9732
1GAL Bag Tox Sample Tamper Proof 1592
CHAIN OF CUSTODY FORM

QTY
NON-DOT (LEGAL) REQS 0804
Account Number

Account Name

DOT (SAMHSA) REQS 0782
Account Number

Account Name

Tox Quick POCT Reqs 0773
Account Number

Account Name

PREPRINT COLLECTION SITE? YES NO

IF YES COMPLETE THIS SECTION
Account Number
Company Name
Street Address
City
State
Zipcode
Phone #
FAX #
  





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