Enrollment Information This request is for enrollment year 2024
Identification Information Contact Information Please enter the contact information of the person completing this form
Name(Required)
First
Last
Type Of Testing Site For This Order Select Type Clinic-large (>20 physicians) Clinic-medium (6-10 physicians) Clinic-small (<6 physicians) Federal (prison/military) Forensic Lab Health Management Organization Home Health/Extended Care Hospital-large (>350 beds) Hospital-medium (100-350 beds) Hospital-small (<100 beds) Independent Clinical Lab Manufacturer Nursing Home Pharmacy Physician Office Lab Point of Care Testing Public Health Lab Research and Development Satellite Lab Screening, Wellness, Fitness Speciality Stat/Urgent Care Lab Student Health Lab Veterans Administration Veterinary Other (Please specify at right)
How did you find us? Please select one(Required)
General (Send Reports To) Address
Billing Information Billing info same as General Address
Shipping Information Shipping info same as General Address(Required)
Consultant Information (optional) Address
Accreditation Agencies List accreditation agency(ies) which monitor the testing done at this site.
Application In Progress Application In Progress Application In Progress Application In Progress
Score transmission to accreditation agencies: Do not send the following scores to agencies All applicable scores will be sent to designated agencies by default unless specified below.
Order Information It may be necessary to refer to our catalog and price list while completing this portion or please upload your quote below.
Please note: Assayed Sample Sets and AUDIT Linearity/Calibration Verification products have separate order forms.
Only Quality Evaluation (QE) and Additional Sample products may be ordered in multiple quantity. All others indicate quantity of 1.
Customers wanting to enroll only in certain events, please indicate so in the Order Comments section. You will only be charged for events enrolled. Annual processing fee is non-refundable.
Chemistry Check the box below to view the product list.
Chem Sub-specialty Coagulation Check the box below to view the product list.
Coag Sub-specialty Hematology Check the box below to view the product list.
Heme Sub-specialty Immunohematology Check the box below to view the product list.
Immunoheme Sub-specialty Immunology Check the box below to view the product list.
Immuno Sub-specialty Microbiology Check the box below to view the product list.
Micro Sub-specialty
Urinalysis/Microscopy/Misc. Urin-mic-misc Sub-specialty
Point of Care Package Point of Care Package POC Package Product List POC Package Product List POC Package Product List Need quality evaluation (QE) sets? Please order individually. See pg. 55 of our catalog for the reference list.
Online Training and Competency All Medical Training Solutions (MTS) order options include access for up to 30 individuals. See Facility Fees section below (appears when checkbox is selected) for additional users. To refresh this section to make new selections, simply uncheck and then recheck the view options checkbox below.
Check to view Training Order Individual Training & Competency | $125 each List individual Item #s here. Please see the
MTS Product List for individual Item #s
Manual Entry of Products Option To order off-schedule products or to order any proficiency testing products manually, please add the Item #, Product Name, and Product Price each separated by a comma in the text box below.
Enter your off-schedule products and other products manually here:
Upload Documents Upload your quotes or purchase orders
Order Binders
Order Total Annual Processing Fee(Required) Annual processing fee applies to regularly scheduled PT events/shipments and MTS training & competency course-only orders
Payment Information 