Please read and follow our Instructions for Submitting a Sample for Microscopic Examination.
Please fill out this form completely, then click the SUBMIT button at the bottom.
HINT: Use the Tab key to move in between fields.
* indicates a required field


Contact Information

Please provide complete contact information for the party who should receive the laboratory results and the person responsible for the invoice in the areas provided. The party responsible for the invoice also controls the custody of the sample, including who is authorized to discuss laboratory results. We will not discuss results with unauthorized parties.

This form is being completed by: Name : *
Organization : *

Report Results to:
Name : *
Organization : *
Address : *
City, ST Zip : * * *
Phone : *
Fax : *
EMail : *

Report Results via*: Fax   E-mail   Verbal
Send Invoice to: Same as Report Results
Name : *
Organization : *
Address : *
City, ST Zip : * * *
Phone : *
Fax : *
EMail : *

Purchase Order #: (optional)


Sample Information

Please provide as much information about the sample as possible.

Claim Number/Lot Number : *
Specific Product Involved:
Restaurant/Retailer where product was purchased: *

Claimant's Name:
Date of Incident:

Detailed Description of the material to be identified:     *
i.e. glass, bone, blood, black spot, hair, etc. - DO NOT write 'foreign material'; be specific!
 Provide a brief narrative of the circumstances surrounding this sample (Examples):


Services Desired

If you are unsure which options are the most appropriate for your situation, please call the lab at (785) 537-9773.

Laboratory services are billed at $350.00 per hour: 1 hour minimum.
Most routine samples are completed in 1 hour. Large samples, samples with several comparison/reference samples,
and some complicated issues (rodents, condoms, etc) take additional time for analysis.

Type of Service:
Qualitative Microscopy (identify the foreign material)
Forensic Microscopy (identify foreign material and determine how/when the foreign material entered the product)

Additional Options:
Photo-Documentation ($100.00 per sample)
Video-Documentation (call for a quote)
Non-Destructive Testing (Learn More)
Chain of Custody Record (include your form or learn more)
Rapid/Ready Shipping Kit (Learn More)
   Priority:
Standard (6 weeks)
Rush (3-5 business days) : Additional $150 per hour
Same Day Rush : Additional $300 per hour


Sample Storage * (read our sample storage policy):
Destroy after analysis; all samples will be destroyed after 60 days, unless otherwise indicated.

Long-Term Frozen Storage: If you do not have a storage account, the storage fee will be added to your invoice.

Return Sample after analysis: a return charge will apply.


Other Notes or Instructions

Make any further notes or comments here. Be sure to let us know if the party shipping the sample is different from the contact information above, so that we can match your submit form to the sample when it arrives. If additional people should be given authorization to discuss lab results, please include their contact information here.




I understand that by clicking on the "Submit Form" button below, I am ultimately responsible for
the charges incurred during the testing, consulting, and/or examination of the above referenced sample.

Please call us (785-537-9773) or E-mail with any questions.
After you submit the form, you will receive a confirmation and further instructions.