Fill out the Requisition Request Form below. A copy will be automatically sent to Qitek Labs. Requisition Request Account InformationAccount Name*Contact Name*Phone*Email* Address*City*State*Zip Code*RequisitionsHematology and Chemistry (GEORGIA)# of Requisitions NeededToxicology (GEORGIA)# of Requisitions NeededPharmacogenomics (GEORGIA)# of Requisitions NeededPharmacogenomics (OKLAHOMA)# of Requisitions NeededMolecular Microbiology - RPP, UTI, Wound# of Requisitions NeededCancer Genomics (GEORGIA)# of Requisitions NeededCancer Genomics (OKLAHOMA)# of Requisitions NeededParkinson's, Alzheimer's, Dementia (GEORGIA)# of Requisitions NeededParkinson's, Alzheimer's, Dementia (OKLAHOMA)# of Requisitions NeededCardiac - Cardiomyopathy/Familial Hypercholesterolemia (GEORGIA)# of Requisitions NeededCardiac - Cardiomyopathy/Familial Hypercholesterolemia (OKLAHOMA)# of Requisitions NeededCarrier Screening (GEORGIA)# of Requisitions NeededCarrier Screening (OKLAHOMA)# of Requisitions NeededNotificationsName 1 and Name 2 listed below will be notified with shipment information. Name 1Email 1 Name 2Email 2
