Setup

General Information

Primary Interest*

Other Primary Interest

Client Information

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Practitioner Full Name

Name*

First Last

Credentials*

NPI (optional)

Practice Name*

Telephone*

Email*

Office Contact*

Preferred Contact Method*

Preferred Contact Method

Phone
Email

Preferred Day of Week*

Preferred Time of Week*

Are you authorized to order lab testing in your state?*

Are you authorized to order lab testing in your state?

Yes
No

Address*

City / Town*

State*

Postal Code*

Additional Information

Do you practice virtually, in person, or both?

Virtually
In Person
Both

Do you collect specimens on-site at your practice for all patients/clients??

Collect on-site / Have Phlebotomy
Do not collect specimens

Are you seeking new testing that you haven’t ordered before?

Yes
No

Are you seeking laboratory testing that you have previously ordered?

Yes
No

What is the average number of patients/clients you expect to order testing for in a given month?

0-5
5-15
15-30
30+

Are there any specific tests you are seeking immediately?

Anything else that will help us set up your account to meet your needs?

How did you hear about us?

Upload License (Optional)

Max. file size: 50 MB.

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License Uploaded Yes or No

yes
no

hidden field used for Infusionsoft automation

Comments

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Account Set-Up

General Information

Client Information

Additional Information

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