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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
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CLIENT INFORMATION
Facility Name
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Phone
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Address
*
Address 2
City
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State
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ZIP Code
*
Fax No
*
Federal
Commercial
Facility Type
*
Clinical Trial Site
Healthcare Provider
Study Sponsor
Site ID
Protocol No
Quickbook ID
Default Specimen COVID-19
Sales Representative
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Arslan tmit
M Ishfaq
Panels For Testing
*
Infectious Disease
Tox
Blood
Antigen
HLOP
Mobile
STD Control
Client Bill
Dymo Printing
PharmD
This facility sends results to patients
Enable Auto Accession Generation
Monthly Stewardship Reports
Medical Director
Director of Nursing
Executive Director
Requisition
In-House Tox
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CONTACT INFORMATION
Primary Contact Name
*
Title
Primary Contact Phone
*
Primary Contact Email
*
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
Username
Physician Email
(Associated with account login)
Password
Generate Password
Physician Full Name
NPI#
State License #
Title
City
State
Zip
Protocol #
Study Sponsor
Site ID
Phone #
Secure Fax
Primary Physician Signature
Note: Please choose only .JPG | .PNG | .JPEG
image format for the file and use the image size 541 x 122 for the best quality.
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Need to hire new staff
Collector
Phlebotomist
None
Information For Phlebotomist
Yes
No
Special Requests
Specimen Pickup Information
UPS
FEDEX
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
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id
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