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Employers: Supply Order Form
For domestic supply orders only.
Shipping Information
*
Indicates required fields
First name
*
Last name
*
Company name
*
Account number/Site code
*
Phone
*
Email
*
Supplies Requested
Include custody & control forms (CCFs)
*
Yes
No
Quantity
*
Choose
10
20
50
100
Other
If a different quantity is needed, please do not use this form. Instead, email your request to
ES.Orders@QuestDiagnostics.com
.
Collection kit type
Urine – single specimen
Urine – single specimen quantity
Choose
25
50
100
200
Other
If a different quantity is needed, please do not use this form. Instead, email your request to
ES.Orders@QuestDiagnostics.com
.
Include return shipping materials
Yes
No
Urine – split specimen
Urine – split specimen quantity
Choose
25
50
100
200
Other
If a different quantity is needed, please do not use this form. Instead, email your request to
ES.Orders@QuestDiagnostics.com
.
Include return shipping materials
Yes
No
Oral fluid devices
Oral fluid devices quantity
Choose
10
20
50
100
Other
If a different quantity is needed, please do not use this form. Instead, email your request to
ES.Orders@QuestDiagnostics.com
.
Include return shipping materials
Yes
No
Hair specimen kits
Hair specimen kits quantity
Choose
10
20
50
100
Other
If a different quantity is needed, please do not use this form. Instead, email your request to
ES.Orders@QuestDiagnostics.com
.
Include return shipping materials
Yes
No
Shipping Address
Company name
*
Attn
*
Street
*
City
*
State
*
ZIP
*
Overnight shipping
*
(
Domestic only
)
Standard shipping from Quest Diagnostics takes approximately 5-7 business days.
Yes
No
Carrier
*
Choose
FedEx
UPS
Shipping Account Number
Comments/Questions (Domestic only)
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