NBS Kit Orders

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Order Form for Newborn Screening Request Kits (IEM1 and IEM1a) and Associated Supplies

Hospital/Clinic/Office Information ✱

Address below must be where you would like kits to be mailed.

Hospital / Clinic / Office Name:	An answer is requiredHospital / Clinic / Office Name:
ATT To:	An answer is requiredATT To:
Shipping Address	An answer is requiredShipping Address
City	An answer is requiredCity
State	An answer is requiredState
Zip	An answer is requiredInvalid value

Today's Date ✱

Requestor Contact Information *

This information is only to receive confirmation of order and to be contacted with any questions.

First name ✱
Last name ✱
Email ✱	Email is already used by another user
Phone 1

Type of Kit Requested: ✱

Initial Kit (IEM-1)

Repeat Kit (IEM-1a)

Both (IEM-1 & IEM-1a)

None - Supplies only (specify below)

# of Kits Requested:

Enter the number of kits and/or supplies you are requesting below:

# of Initial Kits (IEM-1) ($150)	Invalid numberAn answer is requiredValue out of range# of Initial Kits (IEM-1) ($150)
# of Advanced Initial Kits (See note below)	Invalid numberAn answer is requiredValue out of range# of Advanced Initial Kits (See note below)
# of Repeat Kits (IEM-1a)	Invalid numberAn answer is requiredValue out of range# of Repeat Kits (IEM-1a)
# of Yellow IEM-3 pages (1 pad = 50 pages)	Invalid numberAn answer is requiredValue out of range# of Yellow IEM-3 pages (1 pad = 50 pages)
# of White biohazard (letter size) Envelopes	Invalid numberAn answer is requiredValue out of range# of White biohazard (letter size) Envelopes
# of Courier Mailing Envelopes (1 month = 30 envelopes)	Invalid numberAn answer is requiredValue out of range# of Courier Mailing Envelopes (1 month = 30 envelopes)

Notes:
-Yellow IEM3 are per yellow page (1 yellow = 1 page)
-Courier mailing supplies can be sent by month (max 6 months)

Your order of initial kits will ship once payment is received.

Advanced Kit Information: Up to 50% of your initial kit order can be mailed prior to payment being received. To request this advance, put the number of kits you would like advanced into # of Advanced Initial kits line above.

This option is only available if you do not have a previous open order with pending check.

Payment Type ✱

Check

Online Payment

No Payment Needed (Repeats/Supplies Only)

Payment Information:

Check
Make checks payable to "New Jersey Department of Health".
Checks are to be mailed to:

New Jersey Department of Health - Newborn Screening Laboratory
PO Box 371 Trenton, NJ 08625-0371

Online Payment
Online payments via eCheck or credit card can be completed at:
(OPTION COMING SOON!)

When paying by either method, must include the order number that will be provided to you via confirmation email after placing this order.

Any Further Details or Comments: