For Internal Use Only
Test Request Form
Sample #:
Ship Samples To:
Rec’d by
Avista Pharma Solutions • Attn: Sample Login
Date/Time
104 Gold St. • Agawam, MA 01001
Rec’d Via:
Email: login‐ma@avistapharma.com
Billing / Requestor Information
PO #:
Quote #: (if applicable)
Report Attn:
Send Invoice To:
Company:
Company:
Address:
Address:
City/State/Zip
City/State/Zip:
Phone:
Phone:
E‐mail:
E‐mail:
Standard
Tier 1 STAT
Tier 2 STAT
Tier 3 STAT
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Turnaround Time:
TAT
(50% surcharge/test)
(100% surcharge/test)
(200% surcharge/test)
Sample Information and Required Testing
Sample Description
Test
Test
Client SOP #
Quantity
Lot #
(use description desired on final report)
Code
Specification
(if applicable)
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Are microbial IDs required?
Yes (additional fees apply)
No
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What is being identified?
All morphologies
Top predominant morphologies
Other
(detail in ID Comments)
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Standard TAT
Expedited TAT
STAT TAT
Turnaround Time:
(10 Day, MID.1161.10Day)
(4 Day, MID.1161.4Day)
(2 Day, MID.1161.2Day)
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N/A
ID Comments:
Sample Handling Information
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Ambient
On ice
Ambient
2 – 8 °C
Shipping Condition:
Storage Condition:
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On dry ice
‐ 15 ‐ ‐25 °C
‐55 ‐ ‐95°C
Hazardous (fill out below)
Controlled Substance (fill out below)
Sample
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Characteristics:
Hazard 1
DEA #
(check all that apply)
Hazard 2
DEA Schedule
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Discard all samples
Return All Samples*
Return unused portions only*
Sample Disposition:
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*Return via:
FedEx
UPS
Shipping Account #
Additional Testing Comments
☐ N/A
Signature: ______________________________
Date: _________________
Page _____ of _____
I have read and agree to the General Terms and Conditions as listed in the quotation.
A Test Request Form and Purchase Order (PO) must be submitted with the product to initiate product testing services.
Failure to submit completed Test Request or include a PO may result in testing delays.