PGx Tox form - ADV GEN

PGx Tox form - ADV GEN

This little PGx piggy went to the Tox Form Preview
HOSPITAL LAB - PHYSICIAN REGISTRATION FORM
  • PHYSICIAN ENROLLMENT FORM:

    Please complete the Practice Registration Form with as much information as possible.  If you have not already done so please print off the Acknowledgement and Signature Form and have each physician sign and upload it at the bottom of this page.

    Supply Orders
    Supplies on all new accounts will be shipped out the same day if the order is in before 1:00pm CT via overnight express shipping. Please NOTE supplies will be shipped to arrive at anytime the day after they are shipped between 9:00am and 3:00pm to the practice.

    Print the Acknowledgement and Signature Form.

  • ACCOUNT MANAGER INFORMATION:

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  • PRACTICE AND PHYSICIAN INFORMATION:

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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 INFORMATION:

  • COLLECTOR INFORMATION (optional):

  • REPORTING PORTAL INFORMATION (Web - Secure Portal) MUST BE STAFF MEMBER:


  • SUPPLIES

  • You will be able to order supplies on the next page, once you submit the registration form. 

    If they have multiple locations please be sure to order supplies for each.

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    Pick a Date
  • UPLOAD Signature Form
  • Should be Empty: