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

Add Additional Contact

Critical Contact Details

Critical Contact Name

Critical Contact Phone Number

Critical contact Email

Add Additional Critical Contact

Provider Information

Account Activation Type :

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

Physician Full Name*

NPI# *

State License #

Primary Physician Signature

Add User

Special Requests

Specimen Pickup Information

UPS COURIER FEDEX 4M REP

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

Provider Information

Special Requests

Specimen Pickup Information

Projected Specimens

Session Expiration

Your session will expire in minutes 0

notifications

ACCOUNT SETUP FORM

CLIENT INFORMATION

CONTACT INFORMATION

Provider Information

Special Requests

Specimen Pickup Information

Projected Specimens