Test Request Form For Internal Tracking Use Request Form Avista Pharma Solutions Attn: Sample...

Test Request Form Avista Pharma Solutions Attn: Sample Management 104 Gold St. Agawam, MA 01001 Email: [email protected] For Internal Tracking Use Receipt Date/Time Login Page _____ of _____ Please fill out form completely Requestor Invoicing (if different from Requestor) PO # Contact Contact Quote # Company Company Turnaround Time (TAT) Address ☐ Standard See quote for TATs and associated fees. City City ☐ Tier 1 STAT State/Zip State/Zip ☐ Tier 2 STAT Phone Phone ☐ Tier 3 STAT E-mail E-mail Sample Handling, Safety, and Disposition - Please include SDS in shipment – Complete ALL Sections Shipping Condition (to Avista) ☐ Ambient Sample Disposition ☐ Discard all samples Hazard Information (check all that apply) ☐ Freezer Pack ☐ Return all samples* ☐ Non-hazardous ☐ Dry Ice ☐ Return unused portions only* ☐ Biological Storage Condition (at Avista) ☐ Ambient *Return via: ☐ FedEx ☐ UPS ☐ BSL 1 Avista cannot receive and does not test BSL 3 materials. ☐ 2-8°C *Account #: ☐ BSL 2 ☐ -20°C (Additional fees may apply, see quote.) ☐ Chemical ☐ -70°C Controlled Substance? ☐ No ☐ Yes Radioactive? ☐ No ☐ Yes If yes, contact Avista for approval and to coordinate shipment/receipt of the material. Unless noted, temperature data/ recorder returned to Requestor. Schedule: ☐ II ☐ III ☐ IV ☐ V ☐ List DEA #: Sample Information and Requested Testing Quantity Lot # Material Name / Sample Description (Will be reflected on final report) CLIENT SOP # Test Code (See quote) Specification (Required) Do you want copies of the raw data? ☐ No ☐ Yes ($75 fee applies) For the testing requested above, are microbial IDs required? ☐ No ☐ Yes Turnaround Times Comments: (If lot number or material name/sample description listed above purposely differs from the sample label, please provide comment) MicroSeq (MID.1161) VITEK (MID.1162) If yes, which morphologies should be identified? ☐ 10 Days ☐ 4 Days ☐ 4 Days ☐ 2 Days ☐ 2 Days Turnaround time clock begins upon attainment of an isolated culture. ☐ All Top predominant ☐ Other (list in Comments) ☐ Do NOT transfer to MicroSeq VITEK does not identify molds. Molds and isolates which were not identified via VITEK will be automatically tested via MicroSeq unless the box above is checked. Additional fees will apply, see quote. Submission of this executed form and the associated samples for testing signifies your acceptance of the terms and conditions incorporated in the Quote or Avista’s general terms and conditions covering these services (http://Avista.Link/TRF_Terms). A completed Request Form and Purchase Order (PO) must be submitted with your sample(s) to initiate login. Providing incomplete information may delay timeline for receiving results. Address

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Transcript of Test Request Form For Internal Tracking Use Request Form Avista Pharma Solutions Attn: Sample...

Test Request FormAvista Pharma Solutions

Attn: Sample Management 104 Gold St.

Agawam, MA 01001 Email: [email protected]

For Internal Tracking Use

Receipt Date/Time

Page _____ of _____

Please fill out form completely Requestor Invoicing (if different from Requestor) PO # Contact Contact Quote # Company Company

Turnaround Time (TAT) Address ☐ Standard

See quote for TATs and

associated fees.

City City ☐ Tier 1 STAT State/Zip State/Zip ☐ Tier 2 STAT Phone Phone ☐ Tier 3 STAT E-mail E-mail

Sample Handling, Safety, and Disposition - Please include SDS in shipment – Complete ALL Sections Shipping

Condition (to Avista)

☐ Ambient

Sample Disposition

☐ Discard all samples Hazard Information (check all that apply) ☐ Freezer Pack ☐ Return all samples* ☐ Non-hazardous☐ Dry Ice ☐ Return unused portions only* ☐ Biological

Storage Condition (at Avista)

☐ Ambient *Return via: ☐ FedEx ☐ UPS ☐ BSL 1 Avista cannot receive and doesnot test BSL 3 materials.☐ 2-8°C *Account #: ☐ BSL 2

☐ -20°C (Additional fees may apply, see quote.) ☐ Chemical☐ -70°C Controlled Substance? ☐ No ☐ Yes Radioactive? ☐ No ☐ Yes

If yes, contact Avista for approval and to coordinate shipment/receipt of the material.

Unless noted, temperature data/ recorder returned to Requestor.

Schedule: ☐ II ☐ III ☐ IV ☐ V ☐ List DEA #:

Sample Information and Requested Testing

Quantity Lot # Material Name / Sample Description (Will be reflected on final report)

CLIENT SOP #

Test Code (See quote)

Specification (Required)

Do you want copies of the raw data? ☐ No ☐ Yes ($75 fee applies)

For the testing requested above, are microbial IDs required? ☐ No ☐ Yes

Turnaround Times Comments: (If lot number or material name/sample description listed above purposely differs from the sample label, please provide comment) MicroSeq

(MID.1161) VITEK

(MID.1162) If yes, which morphologies should be identified?

☐ 10 Days ☐ 4 Days☐ 4 Days ☐ 2 Days☐ 2 DaysTurnaround time clock begins upon attainment of an isolated culture.

☐ AllTop predominant

☐ Other (list in Comments)

☐ Do NOT transfer to MicroSeqVITEK does not identify molds. Molds and isolates which were not identified via VITEK will be automatically tested via MicroSeq unless the box above is checked. Additional fees will apply, see quote.

Submission of this executed form and the associated samples for testing signifies your acceptance of the terms and conditions incorporated in the Quote or Avista’s general terms and conditions covering these services (http://Avista.Link/TRF_Terms). A completed Request Form and Purchase Order (PO) must be submitted with your sample(s) to initiate login. Providing incomplete information may delay timeline for receiving results.

Address

mailto:[email protected]

http://avista.link/TRF_Terms