New Kit and Sample Registration Form Part 2

D-Terminator Kit and Sample Registration

Please complete questions below (* must be answered).
Enter the email you used to establish your account.*
example@example.com
PLEASE WATCH "HOW TO COLLECT BREATH AND SALIVA SAMPLES" BEFORE DOING YOUR TEST.
TELL US ABOUT YOUR KIT AND SAMPLES
Enter kit number (please locate the 6 digit number on the outside of the long, clear plastic bag included in the pouch containing the instructions).*
NOTE: Include hyphen but do not use spaces.
Your Doctor's name*

First NameLast Name
Doctor's phone number*

Area CodePhone Number
Are you sending a saliva or urine sample?*

SalivaUrine
Date and approximate time breath and saliva or urine sample were taken?*
Should be Empty:

D-Terminator Kit and Sample Registration