Rapid Test Device Request Form

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Rapid Test Device Request Form

All Test requests are completed in the order in which they are received. Please allow up to a week for processing.

* Denotes required fields.

* Requested by: Agency Name

* Agency Contact: Name of person submitting request

* Agency ID #:

* Agency Phone #:

* Email Address: contact person

Test-Device-Quantity: How many boxes are you requesting?

1 box (25 kits)    2 boxes (50 kits)    3 boxes (75 kits)    4 boxes (100 kits)

5 boxes (125 kits)    6 boxes (150 kits)    7 boxes (175 kits)    8 boxes (250 kits)

Do you need external rapid controls?

Do you need a thermometer for monitoring temperature of kits or controls?

Do you need Pipettes & Boats for conducting controls?

 Additional Comments or Questions:

Questions: Contact Jamie Flemming at (785) 296-6545 or Fax: (785) 296-4197.