Please read and follow our Instructions for Submitting a Sample for Microscopic Examination.
Please fill out this form completely, then click the SUBMIT button at the bottom.
HINT: Use the Tab key to move in between fields.
* indicates a required field

Contact Information

Please provide complete contact information for the party who should receive the laboratory results and the person responsible for the invoice in the areas provided. The party responsible for the invoice also controls the custody of the sample, including who is authorized to discuss laboratory results. We will not discuss results with unauthorized parties.

This form is being completed by: Name : *
Organization : *

Report Results to:
Name : *
Organization : *
Address : *
City, ST Zip : * * *
Phone : *
Fax : *
EMail : *

Report Results via*: Email Verbal Only
Send Invoice to: Same as Report Results
Name : *
Organization : *
Address : *
City, ST Zip : * * *
Phone : *
Fax : *
EMail : *

*Purchase Order #: (optional)

Sample Information

Please provide as much information about the sample as possible.

Claim Number/Sample Number : *
Specific Product Involved:
Restaurant/Retailer where product was purchased: *

Claimant's Name:
Date of Incident:

Detailed Description of the material to be identified:     *
i.e. glass, bone, blood, black spot, hair, etc. - DO NOT write 'foreign material'; be specific!
Provide a brief narrative of the circumstances surrounding this sample (Examples):

Services Desired

If you are unsure which options are the most appropriate for your situation, please call the lab at (785) 537-9773.

Laboratory services are billed: 1 hour minimum.
Most routine samples are completed in 1 hour. Large samples, samples with several comparison/reference samples,
and some complicated issues (rodents, condoms, etc) take additional time for analysis.

Type of Service:
Qualitative Microscopy (identify the foreign material)
Forensic Microscopy (identify foreign material and determine how/when the foreign material entered the product)

Additional Options:
Photo-Documentation ($100.00 per sample)
RSID Read w/ Photo-Documentation ($150.00 per sample)
SEM EDX Analysis ($150.00 per sample)
Non-Destructive Testing (Learn More)
Chain of Custody Record (include your form or learn more)
Shipping Kit (Learn More)
Standard (3-4 weeks) : $450 per hour
Rush (5 business days) : $600 per hour
Same Day Rush : $750 per hour

Sample Storage * (read our sample storage policy):
Destroy after analysis ($35 Non–Toxic or $50 Toxic) : all samples will be destroyed after 60 days, unless otherwise indicated.

Long-Term Frozen Storage (Rates Vary): If you do not have a storage account, the storage fee will be added to your invoice.

Return Sample after analysis (Return Charge will apply)

Other Notes or Instructions

Make any further notes or comments here. Be sure to let us know if the party shipping the sample is different from the contact information above, so that we can match your submit form to the sample when it arrives. If additional people should be given authorization to discuss lab results, please include their contact information here.

Validation Question

This is a simple question to try to prevent spam. Sorry for any inconvenience.

In order to submit the form, please answer the following question:
How many letters are in "farm"? (Type answer as a digit, i.e. 7)

I understand that by clicking on the "Submit Form" button below, I am ultimately responsible for
the charges incurred during the testing, consulting, and/or examination of the above referenced sample.

Please call us (785-537-9773) or email us at with any questions.

I agree to not tape the sample. Taped samples may incur extra fees.

After you submit the form, you will receive a confirmation page and further instructions.