New Account Registration
Who is completing this form?
*
Sales Rep
Facility / Clinic
Sales Rep Name
First Name
Last Name
Sales Rep Email
example@example.com
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinic Information
Practice Name
*
Does this Practice have multiple locations/clinic sites?
*
Yes
No
Facility/Client Site
Territory Manager
*
Specialty
*
Primary Care
Urgent Care
Pediatric Care
Nursing / Rehabilitation
Surgery
Other
Clinic Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic Phone Number
*
Format: (000) 000-0000.
Secure Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Hours of Operation
*
Hour Minutes
AM
PM
AM/PM Option
until
until
Hour Minutes
AM
PM
AM/PM Option
Days of Operation
*
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Time Zone
*
CST - Central
EST - Eastern
MST - Mountain
PST - Pacific
Patient Estimate
*
Rows
Per Week
Per Month
Total NEW Patients
Total RECURRING Patients
Report Delivery Preference
Online Portal
Automatic Fax
Check the box below to exclude preliminary reports from automatic faxes
Exclude Preliminary Reports (If selected, only FINAL reports will be faxed to clients.)
Facility EMR System
Laboratory Location/Utilization (Select all that apply)
Mobile, AL
Baton Rouge, LA
Clinical Contact Information
For Blood-Testing purposes, critical contact information must be provided.
Critical Contact Name
*
First and Last
Phone Number
*
Please enter a valid phone number
Format: (000) 000-0000.
Critical Contact Notes
Additional Clinic Contacts
Clinic Contact #1
*
First and Last Name
Email
*
example@example.com
Check the box below to grant authorization for portal access
Authorize Portal Access
Clinic Contact #2
First and Last Name
Email
example@example.com
Check the box below to grant authorization for portal access
Authorize Portal Access
Clinic Contact #3
First and Last Name
Email
example@example.com
Check the box below to grant authorization for portal access
Authorize Portal Access
Physician Information
Physician Name
*
NPI
*
Physician Name & NPI
Physician Email
*
example@example.com
Physician Name #2
NPI #2
Physician Name & NPI #2
Physician Email #2
example@example.com
Physician Name #3
NPI #3
Physician Name & NPI #3
Physician Email #3
example@example.com
Physician Name #4
NPI #4
Physician Name & NPI #4
Physician Email #4
example@example.com
Physician Name #5
NPI #5
Physician Name & NPI #5
Physician Email #5
example@example.com
Physician Name #6
NPI #6
Physician Name & NPI #6
Physician Email #6
example@example.com
Additional Notes/Comments
Additional Notes/Comments
Submit
Submit
Should be Empty: