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University of Wisconsin Crest

WSLH Proficiency Testing

Wisconsin State Laboratory of Hygiene

Accuracy Monitoring – CEQAL Order Form

Enrollment Information

Identification Information

Current/previous account ID (if known)
If application in progress, enter "Pending"

Contact Information

Please enter the contact information of the person completing this form
Name(Required)
Example: (123) 456-7980

Billing Information

Fill in ONLY if new customer or information is different than PT enrollment.
Address
Example: (123) 456-7890

Shipping Information

Fill in ONLY if new customer or information is different than PT enrollment.
Check here if the same as billing information
Address(Required)
Example (123) 456-7890

Order Information

HbA1c Monitoring
Creatinine/eGFR Monitoring
Liver Function Monitoring
Lipids Monitoring
Total Cholesterol CDC Certification
Neonatal Bilirubin Monitoring
Therapeutic Drug Monitoring
Urinary Albumin Monitoring
Vitamin D Monitoring
Thyroid Monitoring
Testosterone Monitoring

Payment Information

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions.

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