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

CLIENT INFORMATION

Company or Facility Name*

Address*

Address 2

City*

State*

ZIP Code*

County

Initial Testing :

Tox (Average per month )

DNA (Average per month )

Blood (Average per month )

Others (Average per month )

CONTACT INFORMATION

First Name*

Last Name*

Phone*

Email*

Specialty Type

Number of Physicians Number of Essential Workers

Specialty Type

Preferred Method of Communication to Schedule Follow-up :

Phone

Email

SHIPPING INFORMATION

Requesting reoccurring pick up ? Yes NO (If no,please disregard the following 3 lines)

FedEx Account # (If applicable)

Requested pick up date(s): S M T W Th F Sat ALL

Preferred pick up time (Note 2 hours window)

Location of pick up (Front door,drop off door etc):

Close of business time:

Test Interest:

Rapid Covid-19 IGG/IGM

COVID-19

Specimen Type :

Nasopharyngeal

Approx.Start Date

Month: Day: Year:

Approx.Daily Sample Volume?*

Current EMR