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 Year20222023202420252026 Please select the item(s) that you wish to order Muscle Kits Nerve Kits Fed Ex Airbills Muscle Kits - Specify Quantity Requested (Each kit includes Muscular Dystrophy Biopsy Requisition, Instruction Sheet, Polycon Lidded Container, Specimen Biohazard Bag, Fed Ex Box, Fed Ex Large Shipping Bag, Cork with Coverslip, Precut Foil, Glutaraldehyde Vial, Formalin Vial, Pre-Paid Fed Ex Airbill) Nerve Kits - Specify Quantity Requested (Each kit includes Anatomic Pathology Consultation Requisition, Instruction Sheet, Precut Sutures with weight in vial, 2.5% Buffered Isosmolar Glutaraldehyde in 15 mL conical tube, Specimen Biohazard Bag, Fed Ex Box, Fed Ex Large Shipping Bag, Pre-Paid FedEx Airbill) Fed Ex Airbills - Specify Quantity Requested The UIDL provides complimentary Pre-Paid Fed Ex First Overnight Service for our Muscle and Nerve 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 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.