Fillable Reproductive Donor Supply Request Form printable pdf download

Reproductive Donor Supply Request Form

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FORM# VML-CSS-T-FORM-0006F.003

Page 1 of 1

Effective Date: 05/02/2016

Reproductive Donor

SUPPLY REQUEST FORM

Please fax this form to ViroMed Account Management at 336-436-1812 or

E-mail this form to

LabCorp Account #: __________________________ OR Patient Service Center X-Code: _______________

Ordered by: ___________________________________ Telephone #: ______________________________

Please complete the information below with your ship-to address:

Facility:

Attention:

Address:

City, State, Zip Code:

Supplies are routinely shipped via ground service to arrive 7 – 10 days following receipt of order.

To request overnight delivery, please provide the information below, and overnight charges will be billed to your

air courier account.

Air Courier: _________________________________ Account #: _________________________________

Authorization: _______________________________

QUANTITY

ITEM NAME

ITEM #

ViroMed Direct Shipping Kit, Each

38170G-S

ViroMed Direct Shipping Kit, Case of 12

38170

Please note that each ViroMed Direct Shipping Kit includes the following items: ViroMed direct shipping box, foam interior cooler,

sealing tape, biohazard leakproof bag, Aqui-Pak

6-bay absorbent pouch, ambient gel wrap, two 8.5 mL gel-barrier tubes, three 4

mL lavender-top (K

EDTA) tubes, one GEN-PROBE

APTIMA

Urine Specimen Collection Kit, specimen collection and packing

instructions, FedEx Express Clinical Pak (large), FedEx Saturday Delivery sticker, and FedEx Express Billable Stamp.

Please order test request forms through your local LabCorp supplier.

If you have questions, please call ViroMed Account Management at 800-582-0077.

ViroMed Use Only:

Received by:____________________________________________ Received Date:____________________

Order #:_____________________________________

Revised May 2, 2016

Reproductive Donor Supply Request Form

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