Test Kit Order Form — MED-LIFE DISCOVERIES

Test Kit Order Form

Please complete the form below and we will contact you to confirm your order details.

Name

First Name

Last Name

Company

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Number of GTA-446 Test Kits ($3000.00/kit; $33/sample)

Number of PC-594 Test Kits ($3000.00/kit; $33/sample)