Order Oral Fluid Kits, Supplies, Custody & Control Forms Order Oral Fluid Kits, Supplies, Custody & Control FormsOrder Oral Fluid Kits, Supplies, Custody & Control Forms hereCompany Name(Required)Name of person filling out this form(Required)Email(Required) To the attention of:Person or Department that should receive the supplies, only if different than person submitting this form.Shipping Address - Please note, forms, kits, and supplies must be sent to a physical address. No P.O. Boxes please.(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What are you ordering? Custody & Control Forms (CCF) Oral Fluid Kits Air Bills & Shipping SuppliesSelect all that applyPlease add any other information you think we need to know to facilitate this order.OptionalChoose your laboratory(Required)Select your laboratoryAlere/AbbotCRLLabCorpQuestLegacySelect your lab from the pulldown listGroup (if applicable)Laboratory Account Number(Required)(find it printed on old copies of CCF)Select ProgramSelect ProgramDOT/UrineDOT/Oral FluidNon-DOT UrineNon-DOT Oral FluidQuantity of Custody & Control Forms (CCF)Select Quantity102030405060708090100125150175200Quantity of Oral Fluid KitsSelect Quantity510152025304050You will be billed $9.00 for each Oral Fluid Kit ordered plus shipping.Quantity of Air Bills & Shipping SuppliesSelect Quantity1020304050Preprinted shipping supplies to send specimens to laboratoryI have additional accounts that also need supplies Check hereWhat are you ordering for this additional account ? Custody & Control Forms (CCF) Oral Fluid Kits Air Bills & Shipping SuppliesChoose your laboratory for 2nd account numberSelect your LaboratoryAlere/AbbotCRLLabCorpQuestLegacySelect your lab from the pulldown listGroup (if applicable)Laboratory Account Number(find it printed on old copies of CCF)Select ProgramSelect ProgramDOT/UrineDOT/Oral FluidNon-DOT UrineNon-DOT Oral FluidQuantity of Custody & Control Forms (CCF)Select Quantity102030405060708090100125150175200Quantity of Oral Fluid KitsSelect Quantity510152025304050You will be billed $9.00 for each Oral Fluid Kit ordered, plus shipping.Quantity of Air Bills & Shipping SuppliesSelect Quantity1020304050Preprinted shipping supplies to send specimens to laboratoryI have a 3rd account that also needs supplies Yes, checkedWhat are you ordering for this 3rd account number Custody & Control Forms (CCF) Oral Fluid Kits Air Bills & Shipping SuppliesSelect all that applyChoose your laboratory for the 3rd account numberSelect your LaboratoryAlere/AbbotCRLLabCorpQuestLegacySelect your lab from the pulldown listGroup (if applicable)Laboratory Account Number(find it printed on old copies of CCF)Select ProgramSelect ProgramDOT/UrineDOT/Oral FluidNon-DOT UrineNon-DOT Oral FluidQuantity of Custody & Control Forms (CCF)Select Quantity102030405060708090100125150175200Quantity of Oral Fluid KitsSelect Quantity510152025304050You will be billed $9.00 for each Oral Fluid Kit ordered, plus shipping.Quantity of Air Bills & Shipping SuppliesSelect Quantity1020304050Preprinted shipping supplies to send specimens to laboratoryI understand that I will be billed $9 for each Oral Fluid Kit ordered, plus shipping.(Required) I agree.
