Michels Solution Request Form

Doctor Information

Doctor's Full Name: *Required Field

Practice Address: *Required Field

Include street, suite

City: *Required Field

State: *Required Field

Zip Code: *Required Field

Phone Number: *Required Field

Please provide the best number to reach you for health-related matters

E-mail Address: *Required Field

Fax: *Required Field

Please provide the best number for us the fax any details.

NPI Number: *Required Field

Additional Information

How did you hear about our biopsy service?

Biopsy kits containing Michel's Solution will be sent via 2 day FedEx delivery and will include a specimen container filled with Michel's solution for acquired specimen, a specimen container filled with 10% Neutral Buffered Formalin for accompanying specimen, submission form, other pertinent documents, and a letter to disseminate to your patient regarding billing. Also included in the kit will be a pre-paid FedEx air bill for the return of the specimen to our lab for processing..

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713-486-4444

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