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Please provide us the following information about you, your organization, your relationship to the organization, the type of the organization, business hours of your practice, an average number of anticipated weekly specimens and wether you require a daily pick up or the pick up on call. Our Account Representative will be in touch with you for some additional sensitive information that we don't collect via web. Right after that We will be at your service.
Last Name:   First Name:   
Your Title: * Other:  
Practice Name:   Type:  
Address:   City:   
State/Prov:   Zip Code:   
Country: Phone:   
Fax:   Email:   
Require EMR Interfaces?:   Require Web Outreach?:  
Require daily Pickup?:   Av Weekly Sp.  
Note :
Your Business Hours (Choose Closest Timings if not in list) :   To:    

Help

All red labeled fields on the left form, are required except the one labled '* Other' as long as the selected value in the 'Your Title' field is not 'Unspecified Other'. The field '* Other' becomes required upon selecting the last option 'Unspecified Other'.

Practice name could be First and Last Name for solo practice.

The field labeled 'Require EMR Interfaces' should be checked if you use any EMR and want to interface with our system.

The Require Outreach should be checked if you want to get the results and accession specimens using our website.

Require daily pick up should be checked if you want us to pick up specimens from your office. In which case you must provide us your business hours. An unchecked value of this field means service will be provided to you per 'on call' basis and your business hours are not required.

The field 'Av Weekly Sp,' is the average number of specimens anticipated to be produced by your practice on weekly bases.

The Note field can be used for additional information about your practice.