Test Kit Order Form | Wisconsin State Laboratory of Hygiene

Clinical Toxicology Kit Order Form

Agency Identifier

Agency Name(Required)

Agency Contact Name(Required)

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Enter Email Confirm 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

Verification