Versiti - Genetic Testing Kit Request Form | Hematology Genetics Testing

Genetic Testing Kit Request Form

Thank you for your interest in Versiti Hematology Genetics. To request buccal (cheek swabs) and/or blood collection kits (EDTA – Purple Top tubes) for Clinical testing, please complete the form below.

You will need your Versiti client ID number to complete the request.

Client Number

To receive your client number, or for NEW clients who have not used Versiti Hematology Genetics testing in the past, please contact Versiti client services at 800-245-3117 x 6250, or Labinfo@versiti.org to set up your account before placing your kit request.

Megan Frey

Field Marketing Manager, Hematology

mfrey@Versiti.org

Kit Request Form

* Institution Name

* Institution Client ID

Requestor Information

* Requestor Role

* First Name

* Last Name

* Email Address

Phone Number

Shipping Address

ATT

* Address

Apartment, Suite, etc

* City

* State

* ZIP

Kit Preferences

Buccal Kit Quantity

Blood Collection Kit Quantity

Date Supplies Needed

Additional Comments

* Fields are required.

Genetic Testing Kit Request Form

Client Number

Megan Frey

Kit Request Form

Requestor Information

Shipping Address

Kit Preferences

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