Account Setup Form

Note: All information with a red asterisk ( * ) must be completed

Patient Information
Month: Day: Year:
I decline To Provide Email

I decline To Provide Phone No


Medical Necessity *
Billing Information









PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

By selecting the Add Signature button, I attest that I approve of this digital signature

I hereby consent to Vero Lab, LLC performing the designated test(s) on the DNA sample provided by me. My signature below constitutes my acknowledgment that Read more