Fillable DNA And PCR Testing Services

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DNA And PCR Testing Services

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Country:
Sampled By Name: Sampled By Signature:
ERMI Panel (M180) Dust Only
Human Bacteroides (M199) Bed Bug (Cimex lectularius ) (M146)
EPA 36 Panel (M233) Air, Swab
Total Bacteroides (M095)
Air, Swab Water Damage 20 Panel (M181)
E. coli O157:H7 (M140)
Aspergillus 15 Panel (M186) Total Enterococcus (M096) Tick - Babesia microti Babesiosis (M260)
Aspergillus 6 Panel (M188) Helicobacter pylori (M207) Tick - Borrelia burgdorferi Lyme disease (M196)
Penicillium 13 Panel (M189) Legionella pneumophila (M103)
Customized Fungi Panel (M100)
Legionella 4 species-EPA (M162) Acanthamoeba spp. (M147)
Penicillium Mycotoxin 9 Panel (M190) Cryptosporidium spp. (M237)
Candida auris (M286) Giardia spp. (M149)
Common Mycotoxin-Producing Fungi 10 (M284)
Leptospira spp. (M262) Naegleria fowleri (M197)
Mycobacterium avium (M144)
Chlamydophila psittaci (M234) Mycobacterium tuberculosis (M159)
Meat Speciation (F132)
Cryptococcus neoformans (M143) Salmonella spp. (M141)
Histoplasma capsulatum (M208) Shigella spp. (F122)
Raccoon Roundworm (M236)
Rodent (Mouse, Rat) Dropping (M271)
Date/Time:
Date/Time:
Controlled Document - COC-08 DNA Testing R7 8/5/2021
Bacteria
Insects
Fungi
Tick - Anaplasma phagocytophilum Anaplasmosis
(M261)
Birds, Animal Droppings
Other
Sample #
Sample Location
Sample Type
Volume/Area
Date/Time Collected
Special Request:
Received by:
Date/Time
EMSL Analytical, Inc.’s Laboratory Terms and Conditions are incorporated into this Chain of Custody by reference in their entirety. Submission of samples to EMSL Analytical, Inc. constitutes
acceptance and acknowledgment of all terms and conditions by Customer.
Method of Shipment:
Sample Condition Upon Receipt:
EMSL LIMS Project ID:
(If applicable, EMSL will provide)
State of Connecticut (CT) must select project location:
No. of Samples
in Shipment
Turn-Around-Time (TAT) Options - Please check
Special Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.)
Relinquished by:
Email(s) for Report:
Email(s) for Invoice:
Purchase
Order:
Project
Name/No:
Project Information
DNA Testing - Chain of Custody
EMSL Order Number / Lab Use Only
Customer Information
Customer ID:
Billing Information
Billing ID:
Company Name:
Street Address:
Street Address:
City, State, Zip:
City, State, Zip:
Country:
Phone:
Phone:
Company Name:
Contact Name:
Billing Contact:
Whole Genome Sequencing & Bioinformatic
Analysis (M285)
DNA Sequencing Fungi/Bacteria Isolates (M192)
Legionella spp. and L. pneumophila serogroup 1
(M164)
Received by:
Date/Time
Relinquished by:
Page 1 of
PHONE:
EMAIL:
AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)
1 Day3 Hour 6 Hour 2 Day 3 Day
1 Week
Commercial (Taxable)
Residential (Non-Taxable)
EMSL Analytical, Inc.
200 Route 130 North
Cinnaminson, NJ 08077
(800) 220-3675
CinnAsblab@EMSL.com
Date/Time:
Date/Time:
Controlled Document - COC-08 DNA Testing R7 8/5/2021
EMSL Analytical, Inc.’s Laboratory Terms and Conditions are incorporated into this Chain of Custody by reference in their entirety. Submission of samples to EMSL Analytical, Inc. constitutes
acceptance and acknowledgment of all terms and conditions by Customer.
Sample #
Method of Shipment:
Sample Condition Upon Receipt:
Relinquished by:
Received by:
Date/Time
Relinquished by:
Received by:
Date/Time
Sample Location
Sample Type
Volume/Area
Date/Time Collected
Additional Pages of the Chain of Custody are only necessary if needed for additional sample information
Special Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.)
DNA Testing - Chain of Custody
EMSL Order Number / Lab Use Only
Page of
PHONE:
EMAIL:
AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)
EMSL Analytical, Inc.
200 Route 130 North
Cinnaminson, NJ 08077
(800) 220-3675
CinnAsblab@EMSL.com
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DNA And PCR Testing Services

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Completed 9 March 2022

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