ACCOUNT SET UP FORM

Prior to any samples received Account Set Up Form must be completed in its entirely ,or there will be a delay in processing.

ACCOUNT SETUP FORM

Company or Facility Name*

Address*

Address 2

City*

State*

ZIP Code*

Initial Testing :

Tox (Average per month )

DNA (Average per month )

Blood (Average per month )

Others (Average per month )

First Name*

Last Name*

Phone*

Email*

Specialty Type

Preferred Method of Communication to Schedule Follow-up :

Phone

Rapid Covid-19 IGG/IGM

COVID-19

COVID-19 & RPP

COVID-19 with Reflex to RPP

other

Month: Day: Year:

Approx.Daily Sample Volume?*

Current EMR*