BioFire Early Access Partner Panels Only – BioFire

Early Access Program – BIOFIRE Panels Only

To review the complete EAP Panel Only Program outline please click here.

Comments
This field is for validation purposes and should be left unchanged.
Sales Manager Information
Your Name
First Last
Sales Territory (Region & Number)*
Your Regional Sales Director's Name*
First Last
Hospital/Facility Information
Hospital/Facility Name
Attention Line
Shipping Address
Street Address Address Line 2 City State ZIP Code
Is this a Teaching Hospital?*
- Yes
- No
Please list the National Provider ID:*
If applicable, please provide IDN:
If applicable, please provide GPO:
Customer Information
Name
First Last
Title
Phone
Email
Does Customer need N/C P.O.?*
- Yes
- No
Panel Information
Please Ship:
- BCID2 KIT (RFIT-ASY-0147)
- ME KIT (RFIT-ASY-0118)
- GI KIT (RFIT-ASY-0116)
- Pneumonia KIT (RFIT-ASY-0144)
- JI Kit (RFIT-ASY-0138)
Installation
Name of FAS doing installation:
Installation Date*
MM slash DD slash YYYY

**All requests require 5-7 business days to process.
Notes
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