Agdia Online Sample Submission Form

Sample Submitted By: (All Fields Required)

Submitters Name:      Company Name: 

Address: 

City:      State:      Zip: 

Phone:      Fax:      Email: 

Send Invoice To: (All Fields Required)  Check if Same as Above

Please note, if invoice is being sent to a third party, the recipient of the invoice must sign off on the form prior to samples being tested by our laboratory.

Attn:      Company Name: 

Address: 

City:      State:      Zip: 

Phone:      Fax:      Email: 

Payment Method

Bill to Purchase Order: 

Check

Credit Card: If this payment type is selected you will receive a form via e-mail from website@agdia.com. Please print the form, fill in the credit card information, sign the form, and fax it back to Agdia at 1-574-264-2153.

Upload your Sample Identification Spreadsheet. (Excel Files Only)

Upload Here

Click browse, select the excel file containing your sample information, then click OK.

Indicate what tests or screens you would like tested on your samples:

Send Extra Copy of Report To:

If you elect this option you will be required to fax this form back to Agdia with your name and signature authorizing us to send a copy of your report to a 2nd or 3rd party. Please note that there is a $20.00 fee for additional reporting.

Attn:

Company Name:

Address: 

City:      State:      Zip: 

Phone:      Fax:      Email: