Zoologix equine test order form

submission form

Your submission of samples to Zoologix with this form indicates your acceptance of Zoologix terms and conditions.
Please enclose a hard copy of this completed form with every package of samples 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 information
Company or institution
Contact name
Phone

Email address(es) for your results:

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

Billing address if different from shipping address (cardholder statement address if paying with 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

Payment information - select one
Credit card or debit card (Visa, MasterCard, American Express and Discover accepted)
Card number Expiration date (mm/yy)
Name on card Security code
PLEASE DOUBLE-CHECK YOUR PAYMENT INFORMATION -
IF INCORRECT OR INCOMPLETE, YOUR ORDER WILL BE DELAYED.
- 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 IDs and sample types submitted for each test

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

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

(Attach additional pages as needed)

Send all samples to OUR NEW ADDRESS:
ZOOLOGIX
725 Lakefield Rd, Suite H
Westlake Village CA 91361
USA
Phone 818-717-8880