UIDL Client # * Facility Name * Contact Person * Contact Phone Number * Ship To: Street Address * Department or Room # * City * State * Zip * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Please Select Any Additional Component(s) You Wish to Order Complete Liver Biopsy Kit Fed Ex Airbills Liver Biopsy Requisition Formalin Vial Viral Culture Kits Biohazard Bag - 8”X10” (package of 100) Therapak Transport Box Fed Ex Large Shipping Bags Complete Liver Biopsy Kit - Specify Quantity Requested Each kit includes Biohazard Specimen Bag, Formalin Tissue Vial, Viral Culture Transport Kit, Liver Biopsy Requisition, Liver Biopsy Instruction Sheet, Transport Boxes, Pre-Paid Fed Ex Airbills and Fed Ex Large Shipping Bag Fed Ex Airbills - Specify Quantity Requested The UIDL provides Pre-Paid complimentary Fed Ex Overnight Service for our Liver Biopsy customers. First Order Only: Please provide your Fed Ex account number for the UIDL to use to place an order in the Fed Ex system. Your Airbills will be shipped directly to you by Fed Ex in approximately two weeks. Fed Ex Account Number Liver Biopsy Requisition - Specify Quantity Requested Formalin Vial - Specify Quantity Requested Viral Culture Kits - Specify Quantity Requested Biohazard Bag - 8”X10” - Specify Quantity Requested Therapak Transport Box - Specify Quantity Requested Fed Ex Large Shipping Bags - Specify Quantity Requested Comment(s): CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.