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Courier Facility Request Form
Please provide the following information to request courier services:
Facility Information
Facility Name
Address
Contact Name
Contact Phone
Which nursing station(s)?
Specimen Information
Collection Date
Number of specimen for pickup
Preferred Lab
Lab Location
Lab Account No.
Requested Date of Service
Requested Pick up Time
Please check all of the following boxes that apply to this request
There is at least one
Stat
draw
There is at least one
Routine
draw
Special Remarks
