AUDIT Calibration Verification and Linearity Order Form Enrollment InformationThis request is for enrollment year:(Required)Identification InformationWSLH PT ID (7 digits)Current/previous account ID (if known)CLIA IDIf 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 NameContact NameAddress 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 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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 - LQ Price: $380.00 Quantity CardiacCheck to view Cardiac Please check box to view Cardiac products K737M-5 QuantityBNP Extended - FD Price: $380.00 Quantity K803M-5 QuantityBNP Siemens Atellica - FD Price: $395.00 Quantity K710M-5 QuantityCardiac Markers -FD Price: $375.00 Quantity K906M-5 QuantityCardiac Markers for Ortho Vitros - FD Price: $135.00 Quantity K982M-5 QuantityCardiac Markers for PATHFAST - FD Price: $130.00 Quantity K935M-5 QuantityCardiac Markers for Roche Systems - FD Price: $425.00 Quantity K936M-5 QuantityCardiac Markers for Roche Systems - FLQ Price: $425.00 Quantity K804M-5 QuantityCardiac Markers for Siemens Atellica - FD Price: $375.00 Quantity K717M-5 QuantityD-Dimer - FD Price: $264.00 Quantity K845M-5 QuantityD-Dimer for bioMerieux VIDAS and miniVIDAS - FD Price: $325.00 Quantity K883M-5 QuantityD-Dimer for PATHFAST - FD Price: $330.00 Quantity K958M-5 QuantityD-Dimer for Stago Systems - FD Price: $265.00 Quantity K704M-5 QuantityHomocysteine - LQ Price: $350.00 Quantity K801M-5 QuantityHomocysteine for Siemens Centaur - LQ Price: $350.00 Quantity K705M-5 Quantityhs-CRP - LQ Price: $350.00 Quantity K907M-5 Quantityhs-CRP for Ortho Vitros - LQ Price: $395.00 Quantity ChemistryCheck to view Chemistry Please check box to view Chemistry products K712M-5 QuantityAmmonia / Ethanol - LQ Price: $375.00 Quantity K899M-5 QuantityAmmonia / Ethanol for Abbott Systems - LQ Price: $325.00 Quantity K881M-5 QuantityAmmonia / Ethanol for Roche Systems - LQ Price: $325.00 Quantity K825M-5 QuantityBilirubin - FD Price: $60.00 Quantity K825M-5 QuantityBilirubin for Beckman AU - FD Price: $60.00 Quantity K886M-5 QuantityBilirubin for Roche Systems - FD Price: $65.00 Quantity K701M-5 QuantityGeneral Chemistry - FD Price: $395.00 Quantity K940M-5 QuantityGeneral Chemistry for Abbott Systems Panel 1 - FD Price: $255.00 Quantity K941M-5 QuantityGeneral Chemistry for Abbott Systems Panel 2 - FD Price: $255.00 Quantity K942M-5 QuantityGeneral Chemistry for Abbott Systems Panel 3 - FD Price: $85.00 Quantity K943M-5 QuantityGeneral Chemistry for Abbott Systems Panel 4 - FD Price: $380.00 Quantity K864M-5 QuantityGeneral Chemistry Panel 1 for Alfa Wasserman-FD Price: $100.00 Quantity K943M-5 QuantityGeneral Chemistry Panel 2 for Alfa Wasserman-FD Price: $120.00 Quantity K943M-5 QuantityGeneral Chemistry Panel 3 for Alfa Wasserman-FD Price: $55.00 Quantity K943M-5 QuantityGeneral Chemistry Panel 4 for 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$265.00 Quantity K897M-5 QuantityUrine Chemistry Panel 1 for Abbott Systems - FD Price: $300.00 Quantity K898M-5 QuantityUrine Chemistry Panel 2 for Abbott Systems - FD Price: $250.00 Quantity K828M5 QuantityUrine / Fluids Chemistry for Beckman AU - FLQ Price: $245.00 Quantity DiabetesCheck to view Diabetes Check the box to view Diabetes products K728M-5 QuantityBeta Hydroxybutyric Acid - LQ Price: $380.00 Quantity K703M-5 QuantityHbA1c -FD Price: $350.00 Quantity K761M-5 QuantityHbA1c - FLQ Price: $350.00 Quantity K889M-5 QuantitySpecial Diabetes - FD Price: $385.00 Quantity K922M-5 QuantitySpecial Diabetes for Roche Systems -FLQ Price: $430.00 Quantity Drug Monitoring & AbuseCheck to view Drug Please check the box to view Drug Monitoring & Abuse products K707M-5 QuantityTherapeutic Drug Monitoring - FD Price: $380.00 Quantity K950M-5 QuantityTherapeutic Drug Monitoring for Abbott Systems -FLQ Price: $270.00 Quantity K827M-5 QuantityTherapeutic Drug Monitoring for Beckman AU - FLQ Price: $265.00 Quantity K911M-5 QuantityTherapeutic Drug Monitoring for Ortho Vitros - FLQ Price: $275.00 Quantity K933M-5 QuantityTherapeutic Drug Monitoring for Roche Systems - FLQ Price: $360.00 Quantity ImmunoassayCheck to view Immunoassay Please check the box to view Immunoassay products K928M-5 QuantityAnemia for Roche Systems - FLQ Price: $210.00 Quantity K809M-5 QuantityAnemia for Siemens Atellica - FD Price: $125.00 Quantity K819M-5 QuantityAnemia for Siemens Centaur - FLQ Price: $245.00 Quantity K896M-5 QuantityAnti-Mullerian Hormone for Roche Systems - FLQ Price: $485.00 Quantity K721M-5 QuantityASO - LQ Price: $350.00 Quantity K735M-5 QuantityCystatin C - LQ Price: $150.00 Quantity K927M-5 QuantityFertility for Roche Systems - FLQ Price: $360.00 Quantity K818M-5 QuantityFertility for Siemens Atellica - FD Price: $325.00 Quantity K808M-5 QuantityFertility for Siemens Atellica - FLQ Price: $195.00 Quantity K833M-5 QuantityImmunoassay for Abbott Architect - FD Price: $330.00 Quantity K714M-5 QuantityImmunoassay - FD Price: $425.00 Quantity K957M-5 QuantityiPTH for Abbott Systems - FD Price: $375.00 Quantity K904M-5 QuantityiPTH for Ortho Vitros - FD Price: $350.00 Quantity K934M-5 QuantityiPTH for Roche Systems - FD Price: $350.00 Quantity K813M-5 QuantityiPTH for Siemens Atellica - FD Price: $325.00 Quantity K834M-5 QuantityProcalcitonin for Abbott Architect - FD Price: $380.00 Quantity K841M-5 QuantityProcalcitonin bioMerieux VIDAS and miniVIDAS - FD Price: $380.00 Quantity K842M QuantityProcalcitonin for bioMerieux VIDAS and miniVIDAS Price: $695.00 Quantity K814M-5 QuantityProcalcitonin for Siemens Atellica - FD Price: $380.00 Quantity K720M-5 QuantityRF/CRP - LQ Price: $350.00 Quantity K832M-5 QuantityThyroid for Abbott Systems - FD Price: $130.00 Quantity K926M-5 QuantityThyroid for Roche Systems - FLQ Price: $200.00 Quantity K807M-5 QuantityThyroid for Siemens Atellica - FD Price: $95.00 Quantity K719M-5 QuantityTumor Markers - FD Price: $575.00 Quantity K805M-5 QuantityTumor Markers for Siemens Atellica/Centaur -FD Price: $580.00 Quantity K851M-5 QuantityT-uptake for Tosoh AIA -LQ Price: $95.00 Quantity K764M-5 QuantityVitamin D - FLQ Price: $200.00 Quantity K910M-5 QuantityVitamin D for Ortho Vitros - FLQ Price: $200.00 Quantity K923M-5 QuantityVitamin D for Roche Systems - FLQ Price: $200.00 Quantity ImmunologyCheck for Immunology Please check the box for Immunology products K702M-5 QuantityProtein - LQ Price: $380.00 Quantity Order TotalShipping(Required) Orders of FD Samples and/or LQ Samples - only (ship with ice): $65 Orders of FLQ Samples - only (ship with dry ice): $65 Orders of FLQ with FD and/or LQ will ship in separate packages: $130 Order Total Payment InformationPayment Information Δ
