EventScan© - Order Cancellation Form - EventScan© - Rapid and PCR Testing for Monkeypox (mpox), Covid-19, Flu A/B, Group A Strep, H5N1 Bird Flu

Order Change Form
Please fill out the form below to cancel your order. Upon completion, a copy of this form will be placed on file and your cancellation will be processed.
Primary Contact Person on Order*

First NameLast Name
Your Company (if applicable)
Company Name
Contracted Testing Date(s)*
Enter a singular date or range of dates.
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reason for Event Cancellation*
Please confirm the statement below by marking the checkbox.*

I am authorized to cancel this event and the services that EventScan was scheduled to provide. I understand that submitted payments are non-refundable and I am canceling my order effective immediately upon submission of this form. I understand that my order cannot be rescheduled for another event date per the terms and conditions of my signed service agreement.
Today's Date*

MonthDayYear
Date
Your Signature*

Clear
Should be Empty:

Order Change Form