Zoologix canine and feline test order form

submission form

Please enclose a hard copy of this completed form with every package of specimens shipped to Zoologix. The form should be enclosed inside the outer shipping package but outside the inner leakproof liner -- see shipping instructions.

This form may be completed here and then printed, or printed blank and then completed by hand (please write legibly).

NOTE: For security, your entered data is not transmitted electronically; your data will be deleted when you close your browser.

Client account number if known

Client information
Company or institution
Contact name
Phone Fax
Email

How would you like to receive results?
Fax results to above fax number. Also cc by fax to
Email results to above email address. Also cc by email to

Shipping address
Shipping street address
Shipping street address
City State or province
ZIP or postal code Country

Billing information
Billing address if different from shipping address (provide card holder's statement address here if paying by credit card):
Billing street address
Billing street address
City State or province
ZIP or postal code Country
Billing contact name
Billing contact e-mail address
Billing phone Billing fax

Payment information - select one
Credit card (Visa or MasterCard accepted)
Card type Name exactly as written on card
Card number Expiration date (mm/yy)
- or -
Check enclosed for $
- or -
Wire transfer (email Zoologix for bank routing details)
- or -
Authorized purchase order #
(For clients with a current Zoologix account)

Assay information
Test code or test name (click here to look up)...Sample ID(s) and sample type(s) submitted for each test

(Attach additional pages as needed, or just attach your own list)

Comments, special instructions, relevant clinical info (symptoms, individuals' ages, recent antibiotics, etc.)

(Attach additional pages as needed)

Send all samples to:

Zoologix, Inc.
9811 Owensmouth Ave, Suite 4
Chatsworth CA 91311
USA
Phone 818-717-8880