| 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: |
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20ml (formalin)
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Podiatry requisitions
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60ml (formalin)
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Supply order forms
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Labels (for biopsy bottles) |
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| Biohazard bags: |
Shipping supplies: |
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Dry nail/keratin bags |
Small boxes (2-jar) |
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Small - 6x6 inches - (for 2-jar box insert) |
Intermediate boxes (6-jar) |
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Intermediate - 8x8 inches - (for 6-jar box insert) |
Large container (>6 jars) |
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Large - 12x15 inches with Requisition Pocket - (for FedEx/UPS shipping) |
FedEx clinical pack (mailing bag) |
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FedEx prepaid airbills |
| Swabs: |
USPS prepaid airbills |
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Aerobic Swabs |
UPS clinical pack (mailing bag) |
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Anaerobic Swabs |
UPS prepaid airbills |
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| E Nerve Fiber Density Kit**: |
| ENFD Kit - One biopsy (single location to be sampled) |
| ENFD Kit - Two biopsies (two locations to be sampled) |
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| **Limit 1, will ship as patient is scheduled. |
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| Comprehensive supply kits (indicate quantity): |
| Large box kits: (One 6-jar box, 6 requisitions, six 20ml jars, 1 intermediate biohazard bag, 6 nail bags, 1 FedEx clinical pack, 1 mailing label) |
| Small box kits: (Three 2-jar boxes, six requisitions, six 20ml jars, 3 small biohazard bags, 6 nail bags, 1 FedEx clinical pack, 1 mailing label) |
| Starter kit: (two large box kits and one small box kit, Bako lab information) |
| Dehydrated alcohol, for Gout/Crystal analysis (two 20ml jars in one small box) |
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