IBL Supply Request Form

For questions or help with this form, contact IBLSUPORD@dhw.idaho.gov or (208)334-2235 EXT. 226

IBL Supply Order Request Form

Date*

First Name*

Last Name*

Facility*

Ship Attention to:*

Address*

City*

State*

Zip Code*

Telephone*

Email Address*

The Idaho Bureau of Laboratories (IBL) provides selected supplies at no cost, with the
understanding that the supplies will be used for submitting samples to IBL for testing.

The following items are free of charge:

Quantity

Other

Quantity

Notes pertinent to your order

The following items are available for a fee:

QuantiFERON-TB Gold tube kits
@ $9.00/kit (Nil, TB Antigen, and
Mitogen tubes)

Quantity (QuantiFERON)

IBL Supply Order Request Form

*Your total comes to: $0.00