Pre-filled Requisition Order Form

PRE-FILLED REQUISITION ORDER FORM

Pre-filled requisitions can be ordered with a minimum of 50. Please allow up to two-weeks for delivery. Fill out this form for each custom requisition.
Your Name*

First NameLast Name
Your E-mail*
You will receive a confirmation email at this address.
Pre-filled Requisition Details

Type and Quantity of Requisitions*

	Quantity
Infectious Disease
PGx+ Requisitions w/ Medical Necessity
Toxicology
Clinical (Blood)
Dermatology

Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic Location Name (if multiple locations)
Clinic Phone Number*
Please enter a valid phone number.
Clinic Fax Number
Please enter a valid fax number.
Number of providers to be on requisition*
Toxicology is the only requisition that can have up to 4 ordering providers. All other requisitions can only have 1 ordering provider per custom req.
Provider 1

First NameLast Name
Provider 1 NPI
Provider 2

First NameLast Name
Provider 2 NPI
Provider 3

First NameLast Name
Provider 3 NPI
Provider 4

First NameLast Name
Provider 4 NPI
Shipping Information

Please allow up to two-weeks for delivery.
Recipient*
ALL SUPPLIES ARE SHIPPED VIA FEDEX GROUND UNLESS OTHERWISE APPROVED
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Comments
Should be Empty:

PRE-FILLED REQUISITION ORDER FORM