YEARLY EVALUATION SUBSCRIPTION ORDER FORM
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1 Contact Name: Contact Phone: PAGE 1 YEARLY EVALUATION SUBSCRIPTION ORDER FORM DATE: P.O. #: INSTITUTION: LABORATORY CONTACT: Phone: FAX: PURCHASING CONTACT: Phone: FAX: ACCTS PAYABLE PHONE: BILLING ADDRESS: MAILING ADDRESS: SHIPPING ADDRESS: IF APPLICABLE: Tax exempt ID #: FedEx #: UPS #: Special Shipping Instructions: NOTE: Payment obligations will be extended to December 31, 2016 on all Yearly Evaluation Subscription orders received before December 1, For orders placed after December 1, 2016, payment obligations are due net 30 days from the order process date. CALIBRATION VERIFICATION / LINEARITY YEARLY EVALUATION SUBSCRIPTION SCHEDULE: EVENT NAME PRODUCT SHIPS TESTING EVENTS MSC14 (Serum Proteins 2) January January and July MSC1 (CO2, ETOH, FE, NH3, UA*) February February and August MSC16 (Whole Blood Glucose) February February and August MSC2 (BNP/NT-proBNP, hs-crp, TnI/TnT) March March and September MSC10 (Vitamin D) March March and September MSC13 (HbA1c) March March and September MSC3 (Serum Proteins 1) MSC4 (Urine Chemistries) MSC15 (D-Dimer) MSC17 (Tumor Markers) MSC18a (Fertility 1) MSC18b (Fertility 2) MSC5 (CK-MB, MYO) MSC6 (Therapeutic Drugs) MSC7 (Osmolality) MSC11 (PSA) MSC8 (General Chemistries) June June and December MSC9 (Thyroids) June June and December MSC12 (Anemia) June June and December * Vitros customers to run UA in June and December
2 Contact Name: Contact Phone: ORDER FORM PAGE 2 Testing Event: MSC1 (CO2, ETOH, FE, NH3, UA*) Testing Event: MSC2b (NT-proBNP, hs-crp, TnT) Testing Event: MSC4a (Urine Chemistries) Price per instrument: $215 (plus shipping and handling) Product Ships: February (material for 2 testing events) Test Events: February and August CO2 (Carbon Dioxide) ETOH (Ethyl Alcohol) FE (Total Iron) NH3 (Ammonia) UA (Uric Acid)* * Vitros customers to run UA in June and December Testing Event: MSC2a (BNP, hs-crp, Tnl) Price per instrument: $917 (plus shipping and handling) BNP (Brain Natriuretic Peptide) hs-crp (High Sensitivity C-reactive protein) Tnl (Troponin I) Price per instrument: $917 (plus shipping and handling) NT-proBNP (Brain Natriuretic Peptide) hs-crp (High Sensitivity C-reactive protein) TnT (Troponin T) Testing Event: MSC3 (Serum Proteins 1) Price per instrument*: $ (plus shipping and handling) ANALYTES**: AAT (a1-antitrypsin) IGG (Immunoglobulin G) C3 (Complement C3) IGM (Immunoglobulin M) C4 (Complement C4) TRFN (Transferrin) IGA (Immunoglobulin A) * Call for specific configurations and pricing ** Dependent on testing instrument, not all analytes are available Price per instrument: $267 (plus shipping and handling) CL (Chloride) ETOH (Ethyl Alcohol) GLU (Glucose) K (Potassium) Testing Event: MSC4b (Urine Chemistries) NA (Sodium) UA (Uric Acid) UTP (Urine Total Protein) UUN (Urine Urea Nitrogen) Price per instrument: $118 (plus shipping and handling) Instrument Manufacturer(s): CA (Calcium) CREA (Creatinine) MG (Magnesium) PHOS (Phosphorus)
3 Contact Name: Contact Phone: ORDER FORM PAGE 3 Testing Event: MSC4c (Urine Chemistries) Testing Event: MSC6 (Therapeutic Drugs) Testing Event: MSC7 (Osmolality) Price per instrument: $149 (plus shipping and handling) Price per instrument*: $ (plus shipping and handling) Price per instrument: $77 (plus shipping and handling) µalb / ALB (Microalbumin / Albumin) AMY (Amylase) PAMY (Pancreatic amylase) Testing Event: MSC5 (CK-MB, MYO) Price per instrument: $267 (plus shipping and handling) ANALYTES**: ACTM (Acetaminophen) AMIK (Amikacin) CARB (Carbamazepine) DIGN (Digoxin) GENT (Gentamicin) LIDO (Lidocaine) NAPA (N-Acetylprocainamide) PHNO (Phenobarbital) PHYT (Phenytoin) PRIM (Primidone) PROC (Procainamide) QUIN (Quinidine) SALY (Salicylate) THEO (Theophylline) TOB (Tobramycin) VALP (Valproic Acid) VANC (Vancomycin) * Call for specific configurations and pricing ** Dependent on testing instrument, not all analytes are available SOSMO (Serum Osmolality) UOSMO (Urine Osmolality) CK-MB (Creatine Kinase-MB) MYO (Myoglobin)
4 Contact Name: Contact Phone: ORDER FORM PAGE 4 Testing Event: MSC8 (General Chemistries) Testing Event: MSC9 (Thyroids) Testing Event: MSC11 (PSA) Price per instrument: $1,434 (plus shipping and handling) Price per instrument: $312 (plus shipping and handling) Price per instrument: $745 (plus shipping and handling) ALB (Albumin) ALP (Alkaline Phosphatase) BUN (Blood Urea Nitrogen) ALT (Alanine Aminotransferase) CA (Calcium) AMY (Amylase) CHOL (Cholesterol) AST (Aspartate Aminotransferase) CL (Chloride) CK (Creatine Kinase) CREA (Creatinine) GGT (Gamma Glutamyltransferase) GLU (Glucose) LD (Lactate Dehydrogenase) K (Potassium) LIP (Lipase) LAC (Lactate) Bc (Conjugated Bilirubin)** LI (Lithium) DBIL (Direct Bilirubin) MG (Magnesium) TBIL (Total Bilirubin) NA (Sodium) HDL (High density lipoprotein) PHOS (Phosphorus) LDL (Low density lipoprotein) TP (Total Protein) TRIG (Triglyceride) UA (Uric Acid)* * Vitros customers to run UA in June and December ** For Vitros customers CORT (Cortisol) Total T3 (Triiodothyronine) Free T4 (FT4) Total T4 (Thyroxine) TSH (Thyroid Stimulating Hormone) Testing Event: MSC10 (Vit D) Price per instrument: $317 (plus shipping and handling) VIT D (Vitamin D) Prostate-Specific Antigen (PSA) free Prostate-Specific Antigen (fpsa) Testing Event: MSC12a (Anemia) Price per instrument: $350 (plus shipping and handling) FERR (Ferritin) FOL (Folate) Vit B12 (Vitamin B12)
5 Contact Name: Contact Phone: ORDER FORM PAGE 5 Testing Event: MSC12b (Ferritin) Testing Event: MSC14 (Serum Proteins 2) Testing Event: MSC16 (Whole Blood Glucose) Price per instrument: $200 (plus shipping and handling) Price per instrument: $599 (plus shipping and handling) Product Ships: January (material for 2 testing events) Test Events: January and July Price per instrument: $300 (plus shipping and handling) Product Ships: February (material for 2 testing events) Test Events: February and August FERR (Ferritin) ALB (Albumin) CRP (C-reactive protein) HPT (Haptoglobin) PAB (Prealbumin) GLU (Glucose) Testing Event: MSC13 (HbA1c) Price per instrument: $499 (plus shipping and handling) % Glycohemoglobin A1c (HbA1c) Testing Event: MSC15 (D-Dimer) Price per instrument: $492 (plus shipping and handling) D-Dim (D-Dimer) Testing Event: MSC17 (Tumor Markers) Price per instrument: $947 (plus shipping and handling) CA 15-3 (Cancer Antigen 15-3) CA 19-9 (Cancer Antigen 19-9) CA 125 (Cancer Antigen 125) CEA (Carcinoembryonic Antigen)
6 Contact Name: Contact Phone: ORDER FORM PAGE 6 Testing Event: MSC18a (Fertility 1) Testing Event: MSC18b (Fertility 2) Price per instrument: $297 (plus shipping and handling) Price per instrument: $297 (plus shipping and handling) FSH (Follicle-stimulating Hormone) hcg (Human Chorionic Gonadotropin) LH (Luteinizing Hormone) PRL (Prolactin) TSTO (Testosterone) AFP (a1-fetoprotein) DHEA-S (Dehydroepiandrosterone Sulfate) E2 (Estradiol) PRGE (Progesterone)
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