Clinical Facility Fact Sheet (CLS/MT & CLT/MLT)
Institution Name:
Address:
City: State: Zipcode:
Telephone Number: Fax Number:
Indicate whether tests are performed in the following areas:
Hematology Chemistry Microbiology Immunology/Serology
Immunohematology Urinalysis Molecular Diagnostics
Daytime laboratory staff (convert part-time to full-time equivalent):
To help keep spammers from using our forms you will have to type Barton below before submitting
Barton