Api Request For Quote - Aab Users printable pdf download

Request for Quote - AAB Users

1159 Business Park Drive, Traverse City, MI 49686

800-333-0958 Fax: 855-900-6119

Date:

Network Name:

Contact:

Lab Accrediting Agency:

Institution Name:

Lab Accrediting ID#:

Address 1:

CLIA #:

Address 2:

LIS:

City/State/Zip:

API Customer No. (If applicable):

Phone/Fax:

API Representative:

Email:

Representative Email:

Send completed quote to (email or fax#):

Check here if you would like your order shipped to each department in a separate box.

Instructions for completing this form:

1) Fill out the top portion of the form.

2) Using your AAB order confirmation or invoice, check off all the tests you are performing below.

3) Where indicated, answer ALL of the questions regarding instruments and check the analytes tested. List primary instruments first.

4) If you are using any other PT provider, please fill out the appropriate form for that provider.

5) Give the completed form to your API Representative; or FAX to: 855-900-6119; or email it to .

For an accurate and timely turnaround, please answer questions where indicated.

Depending on your source, you may need only to refer to the last two digits for the catalog number or item number.

100110

Hemoglobin A1C, Afinion

100111

Oximetry, Blood

100197

Glycohemoglobin, 5-Vial

100199

Amniotic Fluid

100203

Fecal Lactoferrin

100204

Sweat Chloride

100207

Urinary Eosinophils

100216

Urease, Rapid

100228

Blood Gases, Electrolyes, & Hematocrit

100229

SHBG & Testosterone

100239

Cystanin C

100240

Procalcitonin

100901

Alcohol

100902

Blood Gases

___ pH, pCO2, pO2

___ Other Chemistry

100903

Chemistry, Basic

Qualitative HCG Performed: ___Yes ___No

100904

Chemistry, Comprehensive

Thyroid Instrument:

100905

Chemistry, Basic & Comprehensive

Qualitative Serum HCG Performed: ___Yes ___No

Thyroid Instrument:

100907

Fertility Endocrinology

100908

Fructosamine

100909

Glycohemoglobin

100910

Cardiac Markers/Isoenzymes

100911

Chemistry, Special

Free T3 Performed: ___Yes ___No

100912

Drug Monitoring, Therapeutic

100913

Urinalysis

Urine Sediment Performed: ___Yes ___No

Instrument(s):

100914

Drug Screen, Urine

100915

Pregnancy, Serum or Urine

Test Performed on: ___Urine ___Serum

100916

Glucose, WB, Basic

100917

External Quality Assessment

Api Request For Quote - Aab Users

Related Articles

Related forms

Related Categories