Tennessee Mold Consultants

118 North Peters Road

Suite 173

Knoxville, TN 37922

865-558-9772

Lab Analysis Form

Name: _______________________________________________

Address: _____________________________________________

City: ______________________ State: ____ Zip Code: ________

Phone (with area code): _________________________________

Email: _______________________________________________

Referred by: Website / Friend / Doctor / Other

____________________________________________________

□ I would like to receive my lab results online.

□ I would like to receive my lab results by email.

□ I would like to receive my lab results by regular mail.

If you choose to receive your lab results online, you will receive a notification via email that your lab report is ready to be viewed.

PAYMENT INFORMATION:

Total # of plates: ______ @ $30.00 each = $__________

□ Visa □ MasterCard □ Discover □ American Express

Card #:________ -________-________-________Exp. Date: ____/____CID: ______

□ Enclosed is my check made payable to Tennessee Mold Consultants.

Very Important:

This form MUST be mailed back with the test plate(s) so they are processed properly and analyzed in a timely manner. Please contact us IMMEDIATELY if this form is not returned with the test plate(s). Tennessee Mold Consultants WILL NOT be responsible nor replace lost test plate(s) if this form is not returned with the test plate(s).

***** Please allow 7 to 10 days to process your lab results. *****