Linearity Sample Order Form Enrollment InformationThis request is for enrollment year:(Required) Identification InformationWSLH PT ID (7 digits) Current/previous account ID (if known)CLIA ID If application in progress, enter "Pending"Contact InformationPlease enter the contact information of the person completing this formFacility Name(Required) Name(Required) First Last Phone(Required)Example: (123) 456-7980Email(Required) Billing InformationFacility Name Contact Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African 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DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Example (123) 456-7890FaxEmail(Required) Order InformationIt will be necessary to refer to the Linearity Products price list while completing this portion.Blood GasCheck to view Blood Gas Please check box to view Blood Gas products K727M-5 QuantityBlood Gas Calibration Verification Price: $374.00 Quantity CardiacCheck to view Cardiac Please check box to view Cardiac products K737M-5 QuantityBNP Extended Price: $374.00 Quantity K803M-5 QuantityBNP for Siemens Atellica/Centaur Price: $374.00 Quantity K710M-5 QuantityCardiac Markers Price: $343.00 Quantity K906M-5 QuantityCardiac Markers for Ortho Vitros Price: $120.00 Quantity K982M-5 QuantityCardiac Markers for PATHFAST Price: $120.00 Quantity K935M-5 QuantityCardiac Markers for Roche Systems Price: $120.00 Quantity K804M-5 QuantityCardiac Markers for Siemens Atellica/Centaur Price: $343.00 Quantity K717M-5 QuantityD-Dimer Price: $424.00 Quantity K845M-5 QuantityD-Dimer for bioMerieux VIDAS and miniVIDAS Price: $424.00 Quantity K883M-5 QuantityD-Dimer for PATHFAST Price: $424.00 Quantity K958M-5 QuantityD-Dimer for Stago Systems Price: $325.00 Quantity K704M-5 QuantityHomocysteine Price: $343.00 Quantity K801M-5 QuantityHomocysteine for Siemens Centaur Price: $343.00 Quantity K705M-5 Quantityhs-CRP Price: $343.00 Quantity K907M-5 Quantityhs-CRP for Ortho Vitros Price: $350.00 Quantity K932M-5 QuantityTroponin T for Roche Systems Price: $251.00 Quantity ChemistryCheck to view Chemistry Please check box to view Chemistry products K712M-5 QuantityAmmonia / Ethanol Price: $343.00 Quantity K881M-5 QuantityAmmonia / Ethanol for Roche Systems Price: $343.00 Quantity K825M-5 QuantityBilirubin for Beckman AU Price: $58.00 Quantity K886M-5 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K930M-5 QuantityFructosamine for Roche Systems Price: $374.00 Quantity K703M-5 QuantityGlycohemoglobin (HbA1c) Price: $343.00 Quantity K949M-5 QuantityGlycohemoglobin (HbA1C) for Abbott Systems Price: $343.00 Quantity K983M-5 QuantityGlucohemoglobin (HbA1c) for Bio-Rad Systems Price: $343.00 Quantity K956M-5 QuantitySpecial Diabetes for Abbott Systems Price: $374.00 Quantity K909M-5 QuantitySpecial Diabetes for Ortho Vitros Price: $374.00 Quantity K929M-5 QuantitySpecial Diabetes for Roche Systems Price: $374.00 Quantity K970M-5 QuantitySpecial Diabetes for Siemens Atellica/Centaur Price: $374.00 Quantity Drug Monitoring & AbuseCheck to view Drug Please check the box to view Drug Monitoring & Abuse products K707M-5 QuantityTherapeutic Drug Monitoring Price: $374.00 Quantity K950M-5 QuantityTherapeutic Drug Monitoring for Abbott Systems Price: $259.00 Quantity K827M-5 QuantityTherapeutic Drug Monitoring for Beckman AU Price: $259.00 Quantity K911M-5 QuantityTherapeutic Drug Monitoring for Ortho Vitros Price: $259.00 Quantity K933M-5 QuantityTherapeutic Drug Monitoring for Roche Systems Price: $350.00 Quantity ImmunoassayCheck to view Immunoassay Please check the box to view Immunoassay products K948M-5 QuantityAnemia for Abbott Systems Price: $234.00 Quantity K928M-5 QuantityAnemia for Roche Systems Price: $203.00 Quantity K809M-5 QuantityAnemia for Siemens Atellica/Centaur Price: $117.00 Quantity K819M-5 QuantityAnemia for Siemens Centaur Price: $226.00 Quantity K896M-5 QuantityAnti-Mullerian Hormone for Roche Systems Price: $475.00 Quantity K721M-5 QuantityASO Price: $343.00 Quantity K735M-5 QuantityCystatin C Price: $170.00 Quantity K947M-5 QuantityFertility for Abbott Systems Price: $425.00 Quantity K927M-5 QuantityFertility for Roche Systems Price: $350.00 Quantity K808M-5 QuantityFertility for Siemens Centaur Price: $178.00 Quantity K818M-5 QuantityFertility for Siemens Atellica/Centaur Price: $350.00 Quantity K714M-5 QuantityImmunoassay Price: $399.00 Quantity K833M-5 QuantityImmunoassay for Abbott Architect i Series Price: $330.00 Quantity K957M-5 QuantityiPTH for Abbott Systems Price: $349.00 Quantity K904M-5 QuantityiPTH for Ortho Vitros Price: $349.00 Quantity K934M-5 QuantityiPTH for Roche Systems Price: $349.00 Quantity K813M-2 QuantityiPTH for Siemens Centaur Price: $349.00 Quantity K834M-5 QuantityProcalcitonin for Abbott Architect i Series Price: $374.00 Quantity K841M-5 QuantityProcalcitonin for bioMerieux VIDAS and miniVIDAS Price: $374.00 Quantity K842M-25 QuantityProcalcitonin for bioMerieux VIDAS and miniVIDAS Method Validation Price: $765.00 Quantity K814M-5 QuantityProcalcitonin for Siemens Atellica Price: $374.00 Quantity K720M-5 QuantityRF/CRP Price: $343.00 Quantity K832M-5 QuantityThyroid for Abbott Systems Price: $128.00 Quantity K926M-5 QuantityThyroid for Roche Systems Price: $189.00 Quantity K807M-5 QuantityThyroid for Siemens Atellica/Centaur Price: $80.00 Quantity K719M-5 QuantityTumor Markers Price: 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