NEW CLIENT REGISTRATION
Please complete and submit the form below.
Please select which services are being requested.
Please reply to the confirmation you receive or send an email to firstname.lastname@example.org with the details of each location: Practice NamePhysician(s)AddressPhoneFax
If you don't know please estimate and put a "0" (zero) if it does not apply.
Office Contact Person
NOTE: Urine samples must be refrigerated if they are not shipped within 3 days
All supplies will be shipped to the primary practice address above. If they have multiple locations please specify the supply order instructions in the "comments" section below.