Testing Order Form

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Testing Services Order Form
1. Customer Information
2. Billing Information
Principal Investigator
Customer ID
Project Coordinator
Billing Contact
Project Name
Purchase Order
Institution
PO/Street Address
Building
City
Street Address
State / Prov / Zip
City
Email Address
Phone Number
State / Prov / Zip
Fax Number
Phone Number
Email Address
Please type bioshipper / sample return address
if different from Customer Information
Additional report to
3. Collection Method:
Passive Drool
Oral Swab (SOS)
4. Known Infection Agents?
Yes
No List:
5. Total Number of Tubes Submitted:
Total for Assay #1:
Total for Assay #2:
Total for Assay #3:
Total for Assay #4:
Total for Assay #5:
Children’s Swab (SCS)
Infant Swab (SIS)
Other:
Post-Testing:
Please check as many as applicable
Discard Samples (Fee applies, 30 days after testing)
Archive Samples (Fee applies)
____________
Return Samples (Cost of shipping applies)
____________
Return Shipping Materials ($25 unless return label supplied)
____________
Grid boxes?
Bio-shipper?
____________
Please check if Return Shipping Label is included
____________
6. Test Menu: *Indicates singlet test, all other tests are duplicate. **Flow-rate correction recommended.
**Please indicate total number of each test in #5 above.**
-amylase*, **
DHEA-S**
Melatonin
Androstenedione
DNA Extraction (Archival)
Multiplex (see below)
Adiponectin
DNA Extraction (SNP)
MMP-8
Blood contamination*
EBV-antibody
Progesterone
CMV-Antibody
Estradiol
17-OH Progesterone
Cortisol
Estriol
Secretory IgA**
Cotinine
Estrone
Testosterone
CRP**
DHEA
IL-1β (single plex)
Total protein
IL-6 (single plex)
Uric Acid
For Multiplex testing, please Indicate desired cytokines (minimum of 4):
GM-CSF
IFN-γ
IL-1β
IL-2
IL-6
IL-8
IL-10
IL-12p70
TNF-α
Other:
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Contact the Center: [email protected] | 480.965.6944
Testing Services Order Form
7. Weigh Tubes for flow-rate (charge applies):
8. List tests in order of importance:
Yes
No
9. IRB Information: The IISBR will need a copy of your IRB/IACUC approval letter on file prior to beginning any work on this project.
Do you currently have IRB/IACUC approval for this project from your organization?
Yes
No
Has a copy of your IRB approval been sent to the IISBR?
Yes
10. Quote Information: Please provide quoted prices you have received for this study.
Analyte:
Quoted Price:
No
Notes to IISBR:
***************************************************Do not write below this line *********************************************
Date Received
Sample No.
Inventoried By
IISBR ID
Vial Type
Freezer/Shelf
E-mail Sent
Roster Printed
Box Return Date
Sample Discard Date
Contact the Center: [email protected] | 480.965.6944
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