You must have JavaScript enabled to use this form. Clinic Name Contact Name Email Address Phone: Shipping Address Street Address City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Order a Kit A kit includes: 1 FedEx Shipping Bag, 1 FedEx Shipping Label, 1 Specimen Requisition Form, 1 Formalin Bottle (20 mL), and 1 Michel's Medium Specimen Vial, 1 Specimen Bag. Type of Specialty - None -DermatopathologyImmunodermatologyOral Pathology Quantity of Kits - None -241020 Need Additional Supplies? Individual components are available to order below. This can be in addition to complete kits ordered above OR on their own. Formalin bottle size and quanity 7 mL - None -10255075100250500 20 mL - None -10255075100250500 60 mL - None -10255075100250500 120 mL - None -10255075100250500 Michels Medium bottle size and quantity 7 mL - None -10255075100 20 mL - None -10255075100 Specimen Bags - None -2550100150200250300 FedEx Bags - None -510255075100 FedEx Labels - None -510255075100 Are the kits needed by a certain date? No Yes If yes, enter the date here Leave this field blank Requisition Forms Dermatopathology Oral Pathology Immunodermatology
