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ACCOUNT SETUP FORM

Prior to sending any samples, you need to complete the Account Setup Form below, or there may be a delay in processing.

ACCOUNT SETUP FORM

Delete

CLIENT INFORMATION

Facility Name*

Phone*

Address*

Address 2

Latitude

Longitude

City*

State*

ZIP Code*

Fax No*

Federal

Commercial

Default Specimen COVID-19

Sales Representative *

Panels For Testing * Infectious Disease Tox Blood Antigen

Requisition

Add Location

CONTACT INFORMATION

Primary Contact Name*

Title

Primary Contact Phone*

Primary Contact Email*

Please enter correct format

Location ID

Critical Contact Details

Critical Contact Name

Critical Contact Phone Number

Critical contact Email

Ordering Method :

Paper

Electronic

Preferred method of result notification :

Web Portal

HIPAA Fax #

EMR Direct

Add EMR Email*

SalesRep Contact Info :

Primary Physician Details

Account Activation Type :

Email

Physician Email*
_{(Associated with account login)}

Password*

Generate Password

Physician Full Name*

NPI# *

State License #

Primary Physician Signature

Add User

Special Requests

Specimen Pickup Information

UPSFEDEX

Pickup Time Requested:

Monday

Tuesday

Wednesday

Thursday

Friday

Projected Specimens

PathDNA

CNS & Tick-Borne

X

Eye ENT

X

Gastro

X

Men's Health

X

Nail

X

RPP+

X

Respiratory

X

UTI

X

Women’s Health

X

Wound

X

CGX

CGX

X

PGX

Amplis

X

Toxicology

Oral

X

Urine

X

Blood

Blood Allergy

X

Blood Wellness

X

Please upload files

File

Master Facility Portal

Master facility portal