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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)
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District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
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Maine (ME)
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Michigan (MI)
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Mississippi (MS)
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Nebraska (NE)
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New York (NY)
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Ohio (OH)
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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
Arslan tmit
Nawazish sales Rep
Salesperson TestSalesDx
John Soldevilla
Gina Barron
Rebecca Brady
Fernando Mora
Steven Hall
Austin Hughes
Panels For Testing
*
Infectious Disease
Tox
Blood
PGx
Requisition
In-House Tox
Add Location
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
*
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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