Specimen Pick Up Clinic

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Requesting Facility/Clinic Name

Address

City

State

City Dropbox? in

Zip Code

Requestor's Name

Is the Sample in the Dropbox? (If NO, please provide instructions on how to locate the sample in the notes below)

Insurance or Cash Pay?

Notes (e.g., where sample is on-site or a contact number)

Username or email *

Password *

Remember me