*PROFESSIONAL USE ONLY*
Please enter information, print, sign, then mail or fax form to:
Nephro-Tech, Inc., P.O. Box 16106, Shawnee,
KS 66203
Fax: 913-217-7200
(800) 879-4755

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  • Complete the Information Below if Samples are to be Sent to a Dialysis Unit

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  • Number of Patients

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  • FOR NEPHRO-TECH, INC. USE ONLY – DO NOT WRITE BELOW

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