Public health testing supply order form
Available to county public health agencies, epidemiologists and health care professionals only (used for all public health testing and for all patient testing).

With every order, a requisition form (270/271, 272, or 273 Request for Analytical Services form), will be sent.

A submission receipt will be sent to the email provided.
Email address *
Facility Information
Customer Status *
Customer ID Number
Your answer
Facility or Business Name *
Your answer
Street Address (PO Box not accepted) *
Your answer
Street Address II (Suite, Floor Number, Lab, etc.)
Your answer
City *
Your answer
State *
(Other state name)
Your answer
ZIP Code *
Your answer
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Fax Number
Your answer
Billing Address *
Required
Shipping Address (PO Box Not Accepted) *
Required
Additional Information
Rabies requisition forms can't be emailed. They will be faxed or shipped.
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