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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African 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KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneExample: (123) 456-7890FaxEmail(Required) Shipping InformationFill in ONLY if new customer or information is different than PT enrollment.Check here if the same as billing information Check here if same as billing information Facility Name(Required) Contact Name(Required) Address(Required) 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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-5Blood Gas Calibration Verification Price: $343.00 Quantity: CardiacCheck to view Cardiac Please check box to view Cardiac products K713M-5BNP High Price: $343.00 Quantity: K708M-5BNP Low Price: $343.00 Quantity: K737M-5BNP Extended Price: $343.00 Quantity: K888M-5BNP for RAMP Systems Price: $343.00 Quantity: K803M-5BNP for Siemens Centaur Price: $343.00 Quantity: K892M-5BNP for Siemens Stratus Price: $343.00 Quantity: K710M-5Cardiac Markers Price: $343.00 Quantity: K906M-5Cardiac Markers for Ortho Vitros Price: $110.00 Quantity: K887M-5Cardiac Markers for RAMP Systems Price: $343.00 Quantity: K935M-5Cardiac Markers for Roche Systems Price: $110.00 Quantity: K804M-5Cardiac Markers for Siemens Centaur Price: $343.00 Quantity: K891M-5Cardiac Markers for Siemens Stratus Price: $343.00 Quantity: K891M-5Cardiac Markers for Siemens Stratus Price: $343.00 Quantity: K717M-5D-Dimer Price: $389.00 Quantity: K845M-5D-Dimer for bioMerieux VIDAS and miniVIDAS Price: $389.00 Quantity: K883M-5D-Dimer for PATHFAST Price: $389.00 Quantity: K893M-5D-Dimer for Siemens Status Price: $389.00 Quantity: K704M-5Homocysteine Price: $343.00 Quantity: K801M-5Homocysteine for Siemens Centaur Price: $343.00 Quantity: K705M-5hs-CRP Price: $343.00 Quantity: K932M-5Troponin T for Roche Systems Price: $230.00 Quantity: K982M-5Cardiac Markers for PATHFAST Price: $110.00 Quantity: ChemistryCheck to view Chemistry Please check box to view Chemistry products K712M-5Ammonia / Ethanol Price: $343.00 Quantity: K881M-5Ammonia / Ethanol for Roche Systems Price: $343.00 Quantity: K825M-5Bilirubin for Beckman AU Price: $49.00 Quantity: K886M-5Bilirubin for Roche Systeims Price: $51.00 Quantity: K760M-5Galectin-3 Price: $343.00 Quantity: K701M-5General Chemistry Price: $343.00 Quantity: K940M-5General Chemistry for Abbott Systems Panel 1 Price: $250.00 Quantity: K941M-5General Chemistry for Abbott Systems Panel 2 Price: $250.00 Quantity: K942M-5General Chemistry for Abbott Systems Panel 3 Price: $80.00 Quantity: K943M-5General Chemistry for Abbott Systems Panel 4 Price: $372.00 Quantity: K824M-5General Chemistry for Beckman AU Price: $147.00 Quantity: K900M-5General Chemistry for Ortho Vitros Panel 1 Price: $350.00 Quantity: K901M-5General Chemistry for Ortho Vitros Panel 2 Price: $75.00 Quantity: K902M-5General Chemistry for Ortho Vitros Panel 3 Price: $100.00 Quantity: K903M-5General Chemistry for Ortho Vitros Panel 4 Price: $100.00 Quantity: K880M-5General Chemistry for Roche Systems Price: $292.00 Quantity: K959M-5HbA1c for Abbott Systems Price: $343.00 Quantity: K726M-5ISE Price: $118.00 Quantity: K960M-5ISE + Trigs for Siemens Dimension Systems Price: $115.00 Quantity: K709M-5Lipids Price: $343.00 Quantity: K826M-5Lipids for Beckman AU Price: $147.00 Quantity: K882M-5Lipids for Roche Systems Price: $343.00 Quantity: K905M-5TIBC for Ortho Vitros Price: $180.00 Quantity: K732M-5UIBC Price: $343.00 Quantity: K722M-5Microalbumin / Microprotein Price: $343.00 Quantity: K723M5Urine / Fluids Chemistry Price: $236.00 Quantity: K828M-5Urine / Fluids Chemistry for Beckman AU Price: $222.00 Quantity: DiabetesCheck to view Diabetes Check the box to view Diabetes products K819M-5Anemia for Siemens Centaur Price: $207.00 Quantity: K728M-5Beta-Hydroxybutyric Acid Price: $343.00 Quantity: K736M-5Blood Glucose Price: $125.00 Quantity: K930M-5Fructosamine for Roche Systems Price: $343.00 Quantity: K703M-5Glycohemoglobin A1c Price: $343.00 Quantity: K956M-5Special Diabetes for Abbott Systems Price: $343.00 Quantity: K909M-5Special Diabetes for Ortho Vitros Price: $343.00 Quantity: K929M-5Special Diabetes for Roche Systems Price: $343.00 Quantity: K970M-5Special Diabetes for Siemens Centaur Price: $343.00 Quantity: Drug Monitoring & AbuseCheck to view Drug Please check the box to view Drug Monitoring & Abuse products K821M-4Drugs of Abuse for Beckman AU Price: $520.00 Quantity: K931M-4Drugs of Abuse for Roche Systems Price: $520.00 Quantity: K707M-5Therapeutic Drug Monitoring Price: $343.00 Quantity: K950M-5Therapeutic Drug Monitoring for Abbott Systems Price: $238.00 Quantity: K827M-5Therapeutic Drug Monitoring for Beckman AU Price: $238.00 Quantity: K933M-5Therapeutic Drug Monitoring for Roche Systems Price: $350.00 Quantity: K802M-5Therapeutic Drug Monitoring for Siemens Centaur Price: $343.00 Quantity: ImmunoassayCheck to view Immunoassay Please check the box to view Immunoassay products K948M-5Anemia for Abbott Systems Price: $215.00 Quantity: K928M-5Anemia for Roche Systems Price: $186.00 Quantity: K809M-5Anemia for Siemens Centaur Price: $107.00 Quantity: K819M-5Anemia for Siemens Centaur Price: $343.00 Quantity: K721M-5ASO Price: $343.00 Quantity: K947M-5Fertility for Abbott Systems Price: $425.00 Quantity: K927M-5Fertility for Roche Systems Price: $321.00 Quantity: K808M-5Fertility for Siemens Centaur Price: $163.00 Quantity: K714M-5Immunoassay Price: $343.00 Quantity: K833M-5Immunoassay for Abbott Architect i Series Price: $303.00 Quantity: K904M-5iPTH for Ortho Vitros Price: $320.00 Quantity: K934M-5iPTH for Roche Systems Price: $320.00 Quantity: K813M-5iPTH for Siemens Centaur Price: $320.00 Quantity: K834M-5Procalcitonin for Abbott Architect i Series Price: $343.00 Quantity: K841M-5Procalcitonin for bioMerieux VIDAS and miniVIDAS Price: $343.00 Quantity: K894M-5Procalcitonin for Roche Systems Price: $343.00 Quantity: K842M-2Procalcitonin for bioMerieux VIDAS and miniVIDAS Method Validation Price: $702.00 Quantity: K720M-5RF/CRP Price: $343.00 Quantity: K832M-5Thyroid for Abbott Systems Price: $50.00 Quantity: K926M-5Thyroid for Roche Systems Price: $173.00 Quantity: K807M-5Thyroid for Siemens Centaur Price: $73.00 Quantity: K851M-5T-Uptake for Tosoh AIA Price: $80.00 Quantity: K719M-5Tumor Markers Price: $518.00 Quantity: K805M-5Tumor Markers for Siemens Centaur Price: $518.00 Quantity: K738M-5Tumor Markers - HE4, HER2 Price: $518.00 Quantity: K729M-5Vitamin-D Price: $148.00 Quantity: K910M-5Vitamin-D for Ortho Vitros Price: $180.00 Quantity: K885M-5Vitamin-D for Roche Systems Price: $148.00 Quantity: ImmunologyCheck for Immunology Please check the box for Immunology products K921M-5Anti-SARS-CoV-2 S Price: $287.00 Quantity: K981M-5Interleukin 6 (IL-6) Price: $215.00 Quantity: K702M-5Protein Price: $343.00 Quantity: Order TotalShipping Order Total Payment InformationVISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions. 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