ACCOUNT SET UP FORM

Prior to any samples received Account Set Up Form must be completed in its entirely ,or there will be a delay in processing.

ACCOUNT SETUP FORM

CLIENT INFORMATION

Company or Facility Name*

Add New Facility Name*

Country

Address*

City*

State/Province*

ZIP Code*

POINT OF CONTACT INFORMATION

First Name*

Last Name*

Office Phone*

Cell Phone No*

Email*

ALTERNATIVE CONTACT INFORMATION

First Name*

Last Name*

Office Phone*

Cell Phone No*

Email*

Specialty Type

Specialty Type

Initial Testing :

Tox (Average per month )

DNA (Average per month )

Blood (Average per month )

Others (Average per month )

Preferred Method of Communication to Schedule Follow-up :

Phone

Email

SHIPPING INFORMATION

Test Interest:

Rapid Covid-19 IGG/IGM

COVID-19

COVID-19 & RPP

COVID-19 with Reflex to RPP

other

Approx.Start Date