Medicover Sample Shipment Order Form

This form allows you to submit up to three sample types with one submission. If shipping more than three sample types, please create a second submission.

Medicover Sample Shipment Order Form

"*" indicates required fields

Study Number*

Site Name*

Site Contact Name*

Site Address*

Site Email Address*

Site Phone Number*

Site P/U Hours*

Alternate Contact

Please provide the name, email, and phone number of the alternative contact.

Designated Signatory for Forms

Required Pickup Date*

Required Delivery Date

Sample Type 1

Sample Collection Type*

Sample Type*

Tumor Location Source

Where on the body was the biopsy taken?

Tumor Sample Type*

If Other, Description

Number of Samples*

Sample Shipment Weight

Temperature Requirement

If you are adding another sample type with this shipment, check the box below.

Yes

Sample Type 2

Sample Collection Type*

Sample Type*

Tumor Location Source

Where on the body was the biopsy taken?

Tumor Sample Type*

If Other, Description

Number of Samples*

Sample Shipment Weight

Temperature Requirement

If you are adding another sample type with this shipment, check the box below.

Yes

Sample Type 3

Sample Collection Type*

Sample Type*

Tumor Location Source

Where on the body was the biopsy taken?

Tumor Sample Type*

If Other, Description

Number of Samples*

Sample Shipment Weight

Temperature Requirement

Other Details

Total # of Samples

This field will automatically calculate the total numbers of samples in this shipment.

Destination Name and Address*

Special Requests/Requirements/Comments

Upload Files

Drop files here or

Max. file size: 100 MB.

Please upload files like the CDC Form, Commercial Invoice, and E-Manifest.

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