IMP Registration Form - Tox, Blood, PGX

IMP Registration Form - Tox, Blood, PGX

IMP Registration Form - Tox, Blood, PGX Form Preview
iMPERiUM CLIENT REGISTRATION FORM
  • NEW CLIENT REGISTRATION

    STEP ONE:
    If you have not done so already, please print the appropriate registration forms that require a signature and have each Physician sign them.  You do not need a signature to register your Doctor for PGx testing.  It is up to you whether you want to complete the paper form or not however, we do require that you complete the online registration form below and UPLOAD the "wet" signature forms for our records of acknowledgement. 

    STEP TWO:
    Please complete the online form and upload your signed registration form(s) below if needed.  You will be able to order supplies from this form as well.  You MUST upload a signed registration form for each Physician that will be sending in samples for Toxicology and Genetic Carrier Screening.  (Note:  if the practice is not interested in doing the carrier screen then you do not need to upload that form). 

    Supply Orders
    All supply orders placed by1:00pm CST will be shipped over night express for next day delivery.  All orders submitted after 1:00pm CST will be shipped out the next business day.  Please NOTE supplies will be shipped to arrive at anytime the day after shipped between 9:00am and 3:00pm to the practice.

    CLICK HERE if you do not have the toxicology signature forms that you need to upload.

    NOTE:  The individual who directed you to this registration form should have provided you with their "Distribution Group" code.  If you did not receive this please find out the appropriate code before registering your Practice to help us organize our groups. 

    PLEASE TAKE NOTE OF OUR NEW SHIPPING CUT OFF TIME OF 1:00pm CT.

  •  -
  • Please select which services are being requested.

  •  -
  •  -
  • Insurance Mix

    If you don't know please estimate and put a "0" (zero) if it does not apply.


  • Office Contact Person 


     

  • NOTE:  Urine and DNA samples must be refrigerated if they are not shipped within 3 days

  • SUPPLIES

  • 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.

  •  -  -
    Pick a Date
  • Should be Empty: