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 the Kit and Any Additional Component(s) You Wish to Order Renal Kits (Each kit includes renal transport boxes, Michel’s, Formalin and Glutaraldehyde Vials, Renal Pathology Requisition, Biohazard Bag, Fed Ex Airbill, and Fed Ex Large Shipping Bag) Renal Boxes Michel's Vial Formalin Vial Glutaraldehyde Vial Renal Pathology Requisition Biohazard Bag (8”X10”) (Package of 100) Fed Ex Large Shipping Bags Fed Ex Large Airbills Renal Kits - Specify Quantity Requested Renal Boxes - Specify Quantity Requested Michels Vial - Specify Quantity Requested Formalin Vial - Specify Quantity Requested Glutaraldehyde Vial - Specify Quantity Requested Renal Pathology Requisition - Specify Quantity Requested Biohazard Bag (8”X10”) - Specify Quantity Requested Fed Ex Shipping Bags - Specify Quantity Requested Fed Ex Large Airbills - Specify Quantity Requested The UIDL provides complimentary Fed Ex First Overnight Service for our Renal 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.