Test Kit Order Form | Wisconsin State Laboratory of Hygiene

Clinical Toxicology Kit Order Form

(*) denotes required information.

Agency Identifier

Agency Name *

Agency Contact Name *

Agency Address

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Email *

Note that one blood lead Kit #6 provides materials to test 100 children. The full collection kit contains all of the following components:

• Alcohol swabs
• Sterile gauze pads
• Lancets
• Multivette collection containers with caps
• Labeling tape
• Shipping bags for samples
• Absorbent material
• Adhesive bandages
• Styrofoam mailers/sleeves
• Return address labels (blue on white)
• Toxicology requisition forms—preprinted with agency address and agency account number
• Abbreviated fingerstick collection procedure

If you are requesting the complete Blood Lead Kit #6, enter the number of kits below

For requesting only the Multivette collection containers (one box contains 100), enter below

For requesting only sample submission forms, enter the number below

For requesting only Styrofoam mailing containers and address labels, enter the number below

To order other specific kit components, or for general comments, please use the box below

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