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.

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*

Primary Physician Details

Account Activation Type :

Physician Full Name*

NPI# *

State License #

Need to hire new staff

Collector
Phlebotomist
None

Yes

Special Requests

SHIPPING INFORMATION

UPSFEDEX

Pickup Time Requested:

Requested pick up date(s):

Files

File	Date/Time	Delete