Enrollment Information
Identification Information Contact Information Please enter the contact information of the person completing this form
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Type Of Testing Site For This Order Select Type Clinic-large (>20 physicians) Clinic-medium (6-10 physicians) Clinic-small (<6 physicians) Federal (prison/military) Forensic Lab Health Management Organization Home Health/Extended Care Hospital-large (>350 beds) Hospital-medium (100-350 beds) Hospital-small (<100 beds) Independent Clinical Lab Manufacturer Nursing Home Pharmacy Physician Office Lab Point of Care Testing Public Health Lab Research and Development Satellite Lab Screening, Wellness, Fitness Speciality Stat/Urgent Care Lab Student Health Lab Veterans Administration Veterinary Other (Please specify at right)
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Billing Information Billing info same as General Address
Shipping Information Shipping info same as General Address(Required)
Consultant Information (optional) Address
Accreditation Agencies List accreditation agency(ies) which monitor the testing done at this site.
Application In Progress Application In Progress Application In Progress Application In Progress
Score transmission to accreditation agencies: Do not send the following scores to agencies All applicable scores will be sent to designated agencies by default unless specified below.
Order Information It may be necessary to refer to our catalog and price list while completing this portion or please upload your quote below.
Please note: Assayed Sample Sets, AUDIT Linearity/Calibration Verification , and CEQAL Accuracy Monitoring have separate order forms.
Only Quality Evaluation (QE) and Additional Sample products may be ordered in multiple quantity. All others indicate quantity of 1.
Customers wanting to enroll only in certain events, please indicate so in the Order Comments section. You will only be charged for events enrolled. Annual processing fee is non-refundable.
Chemistry Check the box below to view the product list.
Chem Sub-specialty Coagulation Check the box below to view the product list.
Coag Sub-specialty Hematology Check the box below to view the product list.
Heme Sub-specialty Immunohematology Check the box below to view the product list.
Immunoheme Sub-specialty Immunology Check the box below to view the product list.
Immuno Sub-specialty Microbiology Check the box below to view the product list.
Micro Sub-specialty
Urinalysis/Microscopy/Misc. Urin-mic-misc Sub-specialty PT03400 | Point of Care / PPMP Package Select PT03400, then check two-to-four options below
POC Package Options POC Package Options POC Package Options Point of Care / PPMP - Add-On Modules Need more than four modules in your Point of Care package? Add-on modules may be selected individually.
Point of Care / PPMP - QE Need Quality Evaluation (QE) Sets? QE products are available to order individually.
Online Training and Competency All Medical Training Solutions (MTS) order options include access for up to 30 individuals. See Facility Fees section below (appears when checkbox is selected) for additional users. To refresh this section to make new selections, simply uncheck and then recheck the view options checkbox below.
Check to view Training Training & Competency Product Bundles Please choose from the drop-down options below, if you would like a combination of training course and/or competency test options
Click to select your option PT80900 | Combination All Training & Competency | $800 PT81000 | All Competency Tests | $500 PT80000 | All Training Courses | $500
Order Individual Training & Competency | $100 each List individual Item #s here. Please see the
MTS Product List for individual Item #s
Point of Care | Microscopy Procedures (PPMP) Please click the drop-down field to select your option
Click to select your option PT80520 | PPMP Training Courses | $300 PT81900 | PPMP Competency Assessment | $300 PT81920 | PPMP Training & PPMP Competency together | $500 PT81903 | PPMP Competency Add-on to Lab Training and/or Competency | $200
Point of Care | Waived Test Kits & POC Instruments (WPOC) Please click the drop-down field to select your option
Click to select your option PT81910 | WPOC Competency Assessment | $300 PT81913 | WPOC Competency Assessment Add-on to Training and/or Competency | $200
Facility Fees | PT80910 Additional fees apply for more than 30 users. Please click the drop-down field to select your option
Click to select your option 31-100 users | $100 101-200 users | $200 201-300 users | $300 301-400 users | $400 401-500 users | $500
Manual Entry of Products Option To order off-schedule products or to order any proficiency testing products manually, please add the Item #, Product Name, and Product Price each separated by a comma in the text box below.
Enter your off-schedule products and other products manually here:
Upload Documents Upload your quotes or purchase orders
Order Binders
Order Total Annual Processing Fee Does not apply to off-schedule or evaluation sample request
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