Analytical Request Order Form - Medallion Labs

Page 1 of 2 MED-QL103R2 FORM19000 Plymouth Avenue NorthMinneapolis, MN 55427 Phone: Request Order FormDate:Submittor InformationCompany Name:Address:Contact Name:Title:E-mail:Phone:Signature:Additi onal Results RecipientsName:E-mail:Name:E-mail:Please provide estimates for each sample; especially for fat, minerals and submission for testing constitutes acceptance of the STANDARD TERMS AND CONDITIONS appended to this DescriptionSample IDAnalysis Requested If requesting Fiber, please include a Fat LevelsSpecial Instructions: Rush OrderStandard turnaround time for our assays is 7-9 business days. For a turnaround time of 5 business days, select "Rush Order ". Pricing for RUSH service is InformationCompany Name: Address:Contact Name:E-mail:Phone:Fax:Visa/MasterCard #:Expiration Number:Code:Page 2 of 2 MED-QL103R2 FORM19000 Plymouth Avenue NorthMinneapolis, MN 55427 Phone: TERMS AND CONDITIONSAll services provided by Medallion Laboratories ( Medallion ) are subject to the terms and conditions stated herein.

Samples should be collected, prepared and shipped according to proper procedures and accompanied by a Medallion request form for the desired analysis.

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