Kit Request Form

Specimen collection kits and culture test can only be ordered by licensed practitioners, as recognized by the laws of the state of Pennsylvania. This includes: MD, DO, PA‐C, CRNP, DC, DPM or a certified nurse midwife.

Required fields are indicated with an asterisk.

*First Name:
*Last Name:
*Email:
*Title:
*Type of Practice: Medical
*Address:
Address 2:
*City:
*State:
*Zip:
Country: Only US-based physicians may order kits at this time.
*NPI: Enter 10 Digit #.
*Phone:
Fax:
*Kit Requested: Borrelia Kit  
*Number of Kits Requested:
*How Did You Hear About Us?
Comments:
 
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Advanced Laboratory Services Inc.
501 Elmwood Ave.
Sharon Hill, PA 19079

Phone 855-238-4949
Fax 855-238-4946
Borrelia Kit
ENFD Kit