| Account Information |
| Physician name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Fax: |
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| Requesting party: |
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| Contacting eMail Address: |
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| Pre-filled specimen jars/labels: |
Forms: |
| 20ml (formalin) |
Dermatology requisitions |
| 60ml (formalin) |
Supply order forms |
| Labels (for biopsy bottles) |
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| Biohazard bags: |
Shipping supplies: |
| Intermediate - 8x8 inches - (for 6-jar box insert) |
Intermediate boxes (6-jar) |
| Large- 12x15 inches with Requisition Pocket |
Large container (>6 jars) |
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FedEx clinical pack (mailing bag) |
| Swabs: |
FedEx prepaid airbills |
| Aerobic Swabs |
UPS clinical pack (mailing bag) |
| Anaerobic Swabs |
UPS prepaid airbills |
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| Comprehensive supply kits (indicate quantity): |
| Intermediate box kits: (One 6-jar box, 6 requisitions, six 20ml jars, 1 intermediate biohazard bag, 1 FedEx clinical pack, 1 mailing label) |
| Large container kit: (One >6 specimen container, 10 requisitions, 10 20ml specimen jars, 1 large biohazard bag, 1 FedEx clinical pack, 1 mailing label) |
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| Miscellaneous: |
| Lockbox |
| Fax cartridges (please specify number and model) |
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