SAMPLE INTAKE FORM

PERSONAL Information
DONOR NAME
DATE OF BIRTH

MALEFEMALE

PHONE

ADDRESS
CITY
STATE
ZIP CODE

EMAIL

Billing Information
INVOICECREDIT CARDCHECK ENCLOSEDWIRE TRANSFER

BILLING ADDRESS

CITY
STATE
ZIP CODE

CONTACT EMAIL
SAME AS PERSONAL INFORMATION

MAKE CHECK PAYABLE TO:

KORVALABS, INC.
430 S. CATARACT AVE.
SAN DIMAS, CA 91773

  • BANK NAME: CHASE SOUTH PASADENA CA2-4237
  • ADDRESS: 1305 FAIR OAKS AVE,
    SOUTH PASADENA CA 91030
  • ACCOUNT HOLDER: KORVALABS, INC
  • ROUTING NUMBER: 322271627
  • FOR ACCOUNT NUMBER: Email us at INFO@KORVALABS.COM
  • SWIFT: CHASUS33

sAmPlE Information

URINEBLOODBUCCAL

ds

OBSERVEDUNOBSERVED

3
COLLECTION DATE
COLLECTION TIME

4
DONOR SIGNATURE

5
COLLECTOR SIGNATURE (IF APPLICABLE)
COLLECTION DATE
COLLECTION TIME

Test Requested

CUSTOM PANELS

OUT-OF-COMPETITIONIN-COMPETITIONHEMATOLOGICAL PASSPORTSTEROID PROFILE (URINE)STEROID PROFILE (BLOOD)hGH

ds

OTHER COMPOUNDS

ship to
  • Step 1

    COMPLETE ONE FORM PER SAMPLE AND MAKE SURE THE DONOR HAS SIGNED BOX 4 AND COLLECTOR HAS SIGNED BOX 5 (IF APPLICABLE) IN THE SAMPLE INFORMATION SECTION.

  • Step 2

    CAREFULLY SECURE ALL SAMPLES AND MAKE SURE THEY ARE ALL CLOSED PROPERLY TO AVOID LEAKAGE.

  • Step 3

    INCLUDE ONE COMPLETED FORM PER SAMPLE IN SHIPPING BOX.

  • Step 4

    SHIP WITH TRACKING VIA COMMON CARRIER TO: KORVALABS, INC.
    430 S. CATARACT AVE.
    SAN DIMAS, CA 91773

lab use
  • Container:
  • OPENED
  • SEALED

CONDITION OF SAMPLE AND/OR COMMENTS: