Are you a Physician or other HealthCARE providers interested in our services, please fill up the FOLLOWING Registration Form, and we will get back to you SHORTLY.

Practice Name

Specialty/Type

Phone

(###)

###

####

FAX

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Point of Contact Name

First Name

Last Name

Phone

(###)

###

####

Subject

Preferred Contact Method

REPORT DELIVERY METHOD

Portal (You will be given access to our portal)

Fax

SPECIMEN PICK UP DAYS

M

Tu

W

Th

Fr

M-F

Pickup Time (Opening Time)

Hour

Minute

Second

Pick up (Closing Time)

Hour

Minute

Second

ORDERING PHYSICIAN #1 (NAME)

ORDERING PHYSICIAN #1 (CREDENTIAL)

ORDERING PHYSICIAN #1 (NPI)

We Look Forward To Seeing You

You will receive a confirmation when your paperwork has been accepted.