Test Request Form

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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
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) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are microbial IDs required? 
Yes (additional fees apply) 
  No 
What is being identified? 
All morphologies 
Top          predominant morphologies 
Other 
 
(detail in ID Comments)
Standard TAT 
Expedited TAT
STAT TAT
 
 
Turnaround Time: 
(10 Day, MID.1161.10Day) 
(4 Day, MID.1161.4Day) 
(2 Day, MID.1161.2Day) 
N/A 
ID Comments: 
 
 
Sample Handling Information 
  Ambient 
  On ice 
  Ambient 
  2  –  8 °C 
Shipping Condition: 
Storage Condition: 
 
  On dry ice 
  ‐ 15  ‐  ‐25 °C 
  ‐55  ‐  ‐95°C 
Hazardous (fill out below)
Controlled Substance (fill out below)
Sample 
Characteristics: 
Hazard 1 
DEA #
 
 
(check all that apply) 
Hazard 2 
DEA Schedule
Discard all samples 
Return All Samples* 
Return unused portions only* 
 
 
Sample Disposition: 
*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.
 

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