Hospital/Clinic/Office Information ✱
Address below must be where you would like kits to be mailed.
Hospital / Clinic / Office Name:
Shipping Address
Today's Date ✱
Requestor Contact Information *
Type of Kit Requested: ✱
# 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)
# of Advanced Initial Kits ($150)
# of Repeat Kits
# of Yellow IEMs pages (1 pad = 50 pages)
# of White biohazard (letter size) Envelopes
# of Courier Mailing Envelopes (1 month = 30 envelopes)
# of UPS mailing packs

-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: