Zoologix

order 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 box 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.

Current Zoologix clients: enter account number if known

New clients, or if account number is not known: complete Client, Billing and Payment Information sections below.

Client information
Company or institution
Contact name
E-mail address
Phone Fax

Preferred transmission method for results:
Fax
E-mail

Shipping address (No PO boxes please):
Street address
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 address
Billing address
City State or province
ZIP or postal code Country
Billing contact name
Billing contact e-mail address
Billing phone Billing fax

All clients: please complete payment information and assay information sections below for every order.

Payment information
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 -
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 this test

(Attach additional pages as needed)

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