Registration - Tox Allergy

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
All supply orders placed by 4:00pm EST will be shipped "two day early shipping". All orders submitted after 4:00pm EST will be shipped out the next business day "two day early shipping".
CLICK HERE if you need to print the physician acknowledgement form.
NOTE: The individual who directed you to this registration form should have provided you with their "Group ID". If you did not receive this please find out the appropriate code before registering your Practice to help us organize our groups.
Group ID:*
Please select one
Account MGR:*
Account MGR Phone:*
Area CodePhone Number
Account MGR e-mail*
Please select which services are being requested.
Toxicology (Urine)*
YESNO
Pharmacogenomics*
YESNO
Blood Wellness*
YESNO
Hereditary Cancer*
YESNO
Toxicology (oral)*
YESNO
Finger Prick Allergy*
YESNO
Will the practice be using MEBO?*
Yes pleaseNo thank youWhat's MEBO?
MEBO is a user friendly software program used via table (iPad)
at the practice by the patient that will see if they are eligible/qualified
for a PGX and or Hereditary Cancer Genetic Test.
** HIGHLY RECOMMENDED
Please estimate the monthly volume the best you can so the lab can forcast supply orders.
Tox (Urine)
PGX
Blood
Cancer
Tox (oral)
Allergy
Name of Practice:
Physician Name:*
First NameLast Name
E-mail*
Phone Number*
Area CodePhone Number
FAX
Area CodePhone Number
NPI Number:*
Patient Volume:
Monthly Volume
Type of facility?*
Private PracticeRehabilitation CenterNursing HomeHome Health CareHospitalNone of the above
Do you have more than one location?*
Yes, we have additional locationsNo, we just have one location
How many locations?
Practice Address (accuracy is important for shipping labels)*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Please reply to the confirmation you receive or send an email to bingham@labregistration.com with the details of each location:

Practice Name
Physician(s)
Address
Phone
Fax
Insurance Mix
If you don't know please estimate and put a "0" (zero) if it does not apply.
Commercial*
MediCARE*
MediCAID*
Workers Comp
Cash
Office Contact Person
Hours of Operation:
Office Manager:
First NameLast Name
Same Phone As Above?*
YESNO
Office MGR Phone
Area CodePhone Number
Reporting*
PortalFax
Reporting Fax Number*
Area CodePhone Number
Reporting E-mail*
Shipping Address:
Name
Street Address
CityState
Zip Code
Are there other physicians in this office you would like to add?*
How Many?*
Please List All Doctors and NPI #:
ex: Dr. John Jackson - NPI: 1234567891
FEDEX PICKUP REQUEST
Pickup Times?
1:00pm to 2:00pm2:00pm to 3:00pm3:00pm to 4:00pm4:00pm to 5:00pm5:00pm to 6:00pm6:00pm to 7:00pm
Pickup Location:
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.
Urine Toxicology:
Oral Toxicology:
Full Blood Kits:
PGx Kits:
CGX Kits
FP Allergy Kits
Supply Order Comments:
General Comments:
Start Date:*
MonthDayYear
Date
Signed Acknowledgement Form*
UPLOAD
Cancelof
Title
Should be Empty:

SUPPLIES