Please Print Clearly
Name: _______________________________________________
Address: _____________________________________________
City: ______________________ State: ____ Zip Code: ________
Phone (with area code): _________________________________
Email: _______________________________________________
Referred by: Website / Friend / Doctor / Other
____________________________________________________
Total # of plates: __________
□ 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.
***** Please allow 7 to 10 days to process your lab results. *****
Very Important:
This form MUST be mailed back with the test plate(s) so they are processed properly and analyzed in a timely manor. 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).