NBS Kit Orders

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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 *

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:

Checks can be mailed to:
NJ Department of Health Newborn Screening –Billing Unit
PO Box 371 Trenton, NJ 08625-0371

Checks made payable to:
NJ Department of Health

Your order of initial kits will ship once the check is received.

Enter the number of supplies you are requesting below:

# of Initial Kits ($150)	Invalid numberAn answer is requiredValue out of range# of Initial Kits ($150)
# of Advanced Initial Kits ($150)	Invalid numberAn answer is requiredValue out of range# of Advanced Initial Kits ($150)
# of Repeat Kits	Invalid numberAn answer is requiredValue out of range# of Repeat Kits
# of Yellow IEMs pages (1 pad = 50 pages)	Invalid numberAn answer is requiredValue out of range# of Yellow IEMs 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:
-UPS supplies are by pack (1 pack = 250 envelopes)
-Yellow IEMs 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 the check is received.
Advanced Kit Information: Up to 50% of your initial kit order can be mailed prior to the check being received. To request initial kits to be sent prior to the lab receiving the check, put the number of kits requested into # of Advanced Initial kits. This option is only available if you do not have a previous open order with pending check.

Any Further Details or Comments: