NWLS - Registration Form

NWLS - Registration Form

NWLS - Registration Form Form Preview
NWLS - Registration Form
  • LAB ENROLLMENT FORM:

    STEP ONE:
    If you have not done so already, please print the acknowledgement form if the practice will be sending Toxicology samples for testing and have EACH physician sign.

    STEP TWO:
    Please complete the online form and upload your signed acknowledgement 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.  Blood and PGx accounts do not require an acknowledgement form.

    Supply Orders
    Supplies on all new accounts will be shipped out the next business day via overnight experss shipping.  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 signature forms that you need to upload.

     

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  • Please select which services are being requested.

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  • Insurance Mix

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


  • Office Contact Person 


     


  • Billing


     

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  • 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.

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    Pick a Date
  • UPLOAD SIGNATURE FORMS
  • Should be Empty: