Pickup Request

Please complete the form below to request a local sample pickup. This service is only available for active Modus clients.

Requests submitted before 12:00 PM PST will be scheduled for same-day pickup. Requests submitted after that time may be scheduled for the following business day.
Provider Name*

First NameLast Name
Patient Name*

First NameLast Name
Phone Number*
Pickup Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gate Code (if applicable)
Specimen Type*

WoundUTI
Collection Date*

MonthDayYear
Date
I acknowledge the specimen has been properly marked with 2 patient identifiers and the requisition form has been fully completed.*

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