PCR Testing Order Form

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COMPANY NAME: QLabs, Inc.

ADDRESS: 312 MacCorkle Ave, SE

CITY, STATE, ZIP: Charleston, WV 25314

TELEPHONE: 304-926-0565

ATTENTION/CONTACT: Supply Department

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-- Panel Kits --

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-- Individual Testing Supplies --

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-- Requisition Forms --

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-- Shipping Supplies --

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-- END ITEM LIST --

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Please do not submit any Protected Health Information (PHI).