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

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*

Do not Add Physician

Primary Physician Details

Account Activation Type :

Username

Physician Email
_{(Associated with account login)}

Physician Full Name*

NPI#

State License #

Title*

City

State*

Zip

Protocol #

Study Sponsor

Site ID

Phone #*

Secure Fax

Primary Physician Signature

Add User

Special Requests

Specimen Pickup Information

UPSFEDEX

Pickup Time Requested:

Files

Success! Your file has been uploaded.

File	Date/Time		Delete

Assign Lab Code

id	Lab Name	Insurance Type	Test Type	Lab Code	Is Default	Requisition	Edit	Delete

ACCOUNT SETUP FORM

CLIENT INFORMATION

CONTACT INFORMATION

Primary Physician Details

Special Requests

Specimen Pickup Information

Projected Specimens

Session Expiration

Your session will expire in minutes 0

notifications

ACCOUNT SETUP FORM

CLIENT INFORMATION

CONTACT INFORMATION

Primary Physician Details

Special Requests

Specimen Pickup Information

Projected Specimens