COVID-19 New Account Setup – Ipsum Diagnostics

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?

Yes No

Would You Like To Set Up A Web-Portal for reports?

Yes No

First Name

Last Name

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.

DERM PANELS COMING SOON