Registration - Tox Allergy

Registration - Tox Allergy

Registration - Tox Allergy Form Preview
Registration Form - Bingham - Prima
  • 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.

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  • Please select which services are being requested.

  • Please estimate the monthly volume the best you can so the lab can forcast supply orders.

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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


  • SUPPLIES

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    Pick a Date
  • UPLOAD
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