Client Information

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

Secondary Contact Information:

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

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

Billing Information

Billing Address:

Sample Information

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.

Shipping Information

(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.)

Special Instructions (additional surcharge may be applied)

Additional Reports Requested (additional surcharge may be applied)

Sample Notification

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.


Reserve Samples

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.)