Breath Test Sample Collection Kit Order Form

To place your order online, please complete all the information in fields below and click the green "Submit Form" button. If we have any questions we will reach out to you. Or you can download a fillable PDF of our order form by clicking this link. Once you've completed the downloadable version, please email it to or fax it to 1-888-258-5973. Online ordering through this web-portal is available to customers in the United States only. For customers outside of the United States please contact CDI’s Customer Service Department at 1-888-258-5966 or via email at