PCR Mycoplasma Testing

Client Information

Applies to M-1500, M-1500Q, and M-1550

First Name

Last Name

Company Name

Address 1

Address 2

City

State

Zip

Country

Primary Phone #

Name

Phone #

(Please note: Test Results will only be emailed to the recipients entered in this section.)

Fax to #:

US Mail (same as client information):

US Mail (Alternate address below):

Use Client Address information as billing information

Enter Billing information below

Bill to P.O. #:

Bill to card on file

Bill to new card

Quote Number (if applicable):

Sample Designation This designation will appear on all testing reports

Lot Number

Sample Type

Sample Volume (mL, minimum 1.2 for M-1500 and M-1500Q, minimum 5.6 for M-1550)

Date Sampled (mm/dd/yyyy)

Test/Cat. No.