Specimen Collection Kit Order Form

Please call MolecularMD (1-877-459-4979) to order Specimen Collection Kits/Test Requisition Forms or submit completed form below.

Requestor Information

Requested By	Phone Number
Requesting Physician	Physician Code

Shipping Information

Street Address
Street Address 2
City	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip Code

Items Requested

	Hard Copy Requisition Forms		QTY:
	Blood Specimen Collection Kit(s) Contents: Cardboard box, EDTA tubes, bubble wrap pouch, biohazard bag w/ absorbent, preprinted FedEx Airway Bill, and FedEx Clinical Pak for shipping.		QTY:
	Tissue Specimen Collection Kit(s) Contents: Cardboard box, slide box, tissue collection vial, bubble wrap pouch, biohazard bag, preprinted FedEx Airway Bill, and FedEx Clinical Pak for shipping.		QTY:
Comments and Questions

Terms & Conditions

Please allow 5 business days for delivery.

MolecularMD provides specimen shipping kits only for the collection and transport of lab specimens intended for MolecularMD.