PCR Mycoplasma Testing

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 (mL, minimum 1.2 for M-1500 and M-1500Q, minimum 5.6 for M-1550)

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.

*Bionique requires that clients qualify all sample types/matrices for suitability in this assay. If any sample type has not been previously qualified, or if any component has changed since last qualified, be sure to add an M-1500Q line item to your order for that test article and submit sufficient volume to support two tests. Our PCR Testing Department is available to answer your questions at 518-891-2356.

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:

Expedite services

Pooling

Dilution

Less than Sufficient Volume

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.

PCR Mycoplasma Testing

Client Information

Billing Information

Sample Information

Shipping Information

Special Instructions (additional surcharge may be applied)

Sample Notification

Authorization

Reserve Samples