We would like to register as new practice, reorder supplies or order custom brochures. Please send the following supplies to our facility, we use LENETIX^® Medical Screening Laboratory, Inc. Once registered when returning to the site your data will be remembered after logging in....  SIGN IN IF PREVIOUSLY REGISTERED

Professional Title Suffix:

Contact First Name:

Contact Last Name:

Company:

Address:

Suite or Building #:

City:

State:

Zip:

Phone:

Fax:

E-mail

QUAN ORDERING

 Requisitions

Shipping Stryo Foam Boxes with Cover

Test Tubes

Specimen Bags

FED-EX Forms

Pamphlets Packet Includes:

I would like just pamphlets or supplies.

Complete, Print and Fax this form to 516-248-4436 or Mail to:
LENETIX - 174 Mineola Blvd - Suite #1 -Att: Order Dept - Mineola, NY 11501-2512