New Client Information

New Client Information
Organization/Company Name*
Facility Name (If different from Organization Name)
Organization NPI*
Which EHR do you use?
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facilities (additional Facilities can be added by clicking the '+')*
Organization Phone Number*
Organization Fax Number
Type of Industry*

Solo PractitionerGroup PracticeMulti Special ClinicUrgent CareEmployee HealthAcademic CenterHospitalOther
What is your Organization's Specialty?
Provider's will recieve account access to view results for their patient orders ONLY.
Organization Provider(s) (additional Provider's can be added by clicking the '+')*
Point of Contact Information
Point of Contact will have portal access to view ALL reports for the organization.
Point of Contact(s)*
Other Individuals to Grant Access

Individuals listed below will receive access to the Client Portal.
Organization User(s)*
Test Selection
What test panels are you interested in?*

HematologyGenetic TestingOncologyDrug ScreeningChemistry and ImmunochemistryMolecular Infectious DiseaseAt-Home Test Kits
Comments:
Should be Empty:

Point of Contact Information