Mycoplasma Testing

Applies to M-150, M-155, M-200, M-250, M-300, M-350, M-700, M-750, M-800, M-1000, M-1400, M-1450

First Name

Last Name

Company

Address 1

Address 2

City

State

Zip

Country

Primary Phone #

Email

Secondary Contact Information:

Name

Phone #

Select method(s) of report transmission (up to two): *

(Please note: Test Results will only be emailed to the recipients entered in this section.)

Fax to #:

Email:

US Mail (same as client information):

US Mail (Alternate address below):

Billing Address:

Use Client Address information as billing information

Enter Billing information below

Method of Payment:

Bill to P.O. #:

Bill to card on file

Bill to new card

Quote Number (if applicable):

Sample Designation
This designation will appear on all testing reports

Lot Number

Sample Type

Sample Volume

Date Sampled (mm/dd/yyyy)

Test/Cat. No.

Note: to avoid delays in sample processing, please ensure there are no discrepancies between sample labeling on the submission form and the labeling on shipped samples.

TempTale included in shipment?

Yes

No

BioSafety Level (BSL) of samples:

Level 1

Level 2

(Please note: Samples exceeding BSL 2 are NOT accepted. Contact us before sending known human pathogens. Certain agents such as retroviruses may not be accepted.)

Shipping condition:

Frozen (dry ice)

Cold

Ambient

Does the sample contain antibiotics?

Yes

No

Chain of Custody/CoS documents included?

Yes

No

Select one:

Yes

No

Select appropriate options and/or custom options in field below:

Pooling

Dilution

Bring to Volume

Direct Culture Interim Report - Day 7

Direct Culture Interim Report - Day 14

Direct Culture Interim Report - Day 21

Indicator Cell Culture Assay Interim Report

Clients must notify Bionique by completing this form at least two business days prior to shipping samples. Failure to do so may result in delays to sample processing. Additionally, a copy of this sample submission form must accompany the sample shipment.

I authorize Bionique Testing Laboratories to perform mycoplasma testing services on my sample(s) as per the details provided above, and in accordance with Bionique's Terms and Conditions.

Authorized Contact:

Date:

Sample Shipment Date:

cGMP requirements specified in 21 CFR Subpart 1 - Laboratory Controls, Section 211.170 - Reserve Samples states that a sufficient amount of reserve sample submitted for testing shall be retained.

(Please note: Upon hitting submit, a pdf copy of your sample submission form will be sent to the email address you provided in the contact information. Please print and include with your sample shipment.)

Mycoplasma Testing

Client Information

Billing Information

Sample Information

Shipping Information

Special Instructions (additional surcharge may be applied)

Additional Reports Requested (additional surcharge may be applied)

Sample Notification

Authorization

Reserve Samples