Specimen Pick Up Clinic

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Requesting Facility/Clinic Name

Address

City

State

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?

on-site Pay? instructions

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

4940 Van Nuys Blvd. Ste #304,
Sherman Oaks, CA 91403

Username or email *

Password *

Remember me