CLIA-waived LeadCare® II Information Request Form


How would you prefer us to contact you?



* E-Mail:
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*Title:
*First Name:
*Last Name:
Suffix:
Job Title:
*Company:
*Street:
*City:
*State/Province:
*Zip/Postal code:
*Country/Region:
*Telephone:
Fax:

*What best describes your role? (check all that apply)

Executive Lab manager/ supervisor Lab technician
Researcher Healthcare provider (MD, RN, etc.) Administrative support
Other:

*Are you involved in choosing what tests are performed in your office?

*On average, how many patients do you see per week that require blood-lead tests?

*Who is your preferred medical supplier?

*What percentage of your patient population is covered by Medicaid?

*Can we contact you for follow up and future market-research initiatives?

Questions/Comments