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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
*
Phone
*
Address
*
Address 2
Latitude
Longitude
City
*
State
*
Select
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
ZIP Code
*
Fax No
*
Federal
Commercial
Default Specimen COVID-19
Sales Representative
*
Select
Chris lee
Timothy Stamp
Andrew Knadler
Billy Trujillo
Sultan Ameen
Phil Smith
Jett Voorhees
Adam Hawk
House Account
Clay Bullard
Pete Coulas
Sehban Sales Rep
Ismail Test User
Mike Neroni
Chaz Bagwell
Gerry Banuelos
Crystal Kiezi
Lukas Hughes
salman sale
Mike Steven
Panels For Testing
*
Infectious Disease
Tox
Blood
Antigen
Requisition
In-House Tox
Add Location
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
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
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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