Service

Precision Representative

(your name)

CLIENT INFORMATION

Potential client name:

Company name

Phone #:

Number of people testing

(Must be 10 or more. If in our same state, we may be able to approve less than 10, get with management)

Panel they would like to test for?

(If unknown, go over some panels or put N/A)

Do they want rapid?

(NOT available for DOT)

YES

BOTH RAPID & LAB

UNKNOWN

Location(s) - city & state or zip code

Time of event:

(Type unknown if unknown)

Select the following that applies

CLIENT IS ON HOLD

CLIENT WOULD LIKE A CALL BACK

CLIENT WILL CALL BACK

If client is on hold. what line?

(Phone Line Number)

Additional information

A member from our on-site department will call client/customer back on a quote for on-site testing based on the questionnaire below