Submit a Sample

Please fill out the online submission form and submit. After submission, print the form from your web browser and send along with your sample. If you want to download the pdf version click here.

Contact Info

Date

Report To:

Company Name

Contact Name

Address

City

State

Zip Code

Phone

Fax

Contact's Email

Copy To (additional emails)

Separate multiple addresses with a semi-colon

Invoice To:

P.O. Number

Company Name

Attention

Address

City

State

Zip Code

Phone

Fax

Credit Card (You will be contacted separately to complete your transaction)

Company policy prohibits us from receiving credit card information via email. We will not accept credit card information on this submission sheet.

Product Info

Product Name

Lot # (One form per Lot #)

# of Samples

Sample Size/Amount

Quote Number

Controlled Substance? YesNo

For Schedule I, II, III, IV, V, contact R.D. Labs prior to submission

Schedule

DEA #

Testing Information

Rush Service (Please call for pre-approval)

Is Rush Turnaround Required?

See Terms and Conditions for Details

Yes (Applicable surcharge will apply.)No

Turnaround Date Needed

Preapproval Rush No.

Test Name

Method

Claim (When used in the Limit calculation)

Limits (Acceptance Criteria)

Other Information/Instructions

I have read and agree to the Terms and Conditions

Submitted By