ACCOUNT SETUP FORM

Prior to sending any samples, you need to complete the Account Setup Form below, or there may be a delay in processing.

ACCOUNT SETUP FORM

Facility Name*

Phone*

Address*

Address 2

City*

State*

ZIP Code*

Fax No

Federal

Commercial

EMR

Facility Type

Covid Questionnaire

Enable PharmD

Stat Pickup

Add stations for this facility

Add Location

Primary Contact Name*

Title

Primary Contact Phone*

Primary Contact Email

Please enter correct format

Location ID

Add User

Need to hire new staff

Collector
Phlebotomist
None

Information For Phlebotomist

Yes

UPSFEDEX

Pickup Time Requested:

Files

Success! Your file has been uploaded.

File	Date/Time	Delete

Session Expiration