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NEW ACCOUNT SETUP
To create a new account, fill out the form below.
Practice Information
Practice Name
Practice Address
Address 2
City
State
ZIP
Practice Phone
Practice Fax
Contact Person
Point Of Contact Name
Contact Phone Number
Contact Email
Provider Information
Provider(s) First Name (we need at least one provider)
Provider Last Name
Provider NPI
Portal Instructions
Would You Like Reports Faxed To You?
Would You Like Reports Faxed To You?
Yes
No
Would You Like To Set Up A Web-Portal for reports?
Would You Like To Set Up A Web-Portal for reports?
Yes
No
First Name
Last Name
Email
How Many Kits Do You Need Per Week?
What Frequency Would You Like Your UPS Pickups Scheduled? i.e. Daily, Call In
What Time Would You Like UPS To Pickup? UPS Needs At Least An Hour Pickup Window, e.g. 3-4p.
What Pickup Location Instructions Should We Leave The UPS Driver? i.e. Which Entrance To Go To and/or Who To Speak To About Covid Samples.
SUBMIT