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Pick-Up Request Form

Date Submitted: *

.

Account Name *

Pick-Up Address *

Pick-Up Address 2

City: *

State: *

Zip code: *

Pick-Up Type *

Are you SC House Calls or a DMHC Account? *

Yes

No

Do you have a dropbox? *

Yes

No

If you have a dropbox, is it available after business hours? *

Yes

No

Earliest Pickup Time (ET)

Sample Type(s) *

Refrigerated Blood	Ambient Blood	Frozen Blood
COVID-19	Urine	PGX

Waste Pick-Up Date * +

Location Hours of Operation (ET) *

Upload File

First Name *

Last Name *

Phone *

Email *

Title/Position *

Pick-Up Comment