Progentec Clinical Site Onboarding Form

C L I N I C A L S I T E O N - B O A R D I N G F O R M
Use this form to receive an initial set of test kits from Progentec. The kit will include everything you need to administer and ship (overnight courier) the L-DAI (Lupus Disease Activity Index) and L-FRI (Lupus Flare Risk Index) test requisition and samples directly to Progentec. For any questions or additional information you may contact us at labtest@progentec.com or call 405.216.4818 (EXT 103)
1. Physician / Prescriber Information:

*A separate onboarding form is required for each physician / subscriber
Name (MD/DO/PA/NP) of ordering physician

First NameLast NameSuffix
Email address of ordering physician
For Freshworks email
Auto Responder for Freshworks
NPI Number of ordering physician
2. Clinic / Practice Information:
Practice Name
Practice Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Practice Fax Number (for general inquiries)
Please enter a valid phone number.Format: (000) 000-0000.
3. Enter the contact information for the designated recipient of test kits at this clinic.
4. If test kits should be sent to additional locations beyond the main clinic, enter each site's details below. For multiple sites, click "Add Additional Site" to add more entries.
5. Please confirm that your clinic has the ability to draw blood using kits supplied by Progentec.
If known, please provide:
If you are unable to draw blood using Progentec supplied kits, someone from our team with reach out to you after this form has been submitted.
6. Do you have Monday thru Thursday pickup by overnight courier available at or near your clinic?
Please Specify
Courier Service
7. Progentec offers a secure online portal where your clinic can submit test requisitions and view test results. You may use the portal, paper forms, fax, or any combination of these methods.
How will your clinic submit test requisitions?
How would your clinic like to receive test results?
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
You may continue using paper requisition forms and receiving results by fax, even if you also use the secure online portal. A brief 15–30 minute session will be arranged to show your staff how to use the portal.
8. Notes / Special Instructions:
Should be Empty:

C L I N I C A L S I T E O N - B O A R D I N G F O R M

1. Physician / Prescriber Information:

2. Clinic / Practice Information:

3. Enter the contact information for the designated recipient of test kits at this clinic.

4. If test kits should be sent to additional locations beyond the main clinic, enter each site's details below. For multiple sites, click "Add Additional Site" to add more entries.

5. Please confirm that your clinic has the ability to draw blood using kits supplied by Progentec.

6. Do you have Monday thru Thursday pickup by overnight courier available at or near your clinic?

7. Progentec offers a secure online portal where your clinic can submit test requisitions and view test results. You may use the portal, paper forms, fax, or any combination of these methods.

8. Notes / Special Instructions: