Setup

General Information

Primary Interest*

Other Primary Interest

Client Information

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Practitioner Full Name

Name*

First Last

Credentials*

NPI (optional)

Practice Name*

Telephone*

Email*

Office Contact*

Preferred Contact Method*

Preferred Contact Method

Phone
Email

Preferred Day of Week*

Preferred Time of Week*

Are you authorized to order lab testing in your state?*

Are you authorized to order lab testing in your state?

Yes
No

Address*

City / Town*

State*

Postal Code*

Additional Information

Do you practice virtually, in person, or both?

Virtually
In Person
Both

Do you collect specimens on-site at your practice for all patients/clients??

Collect on-site / Have Phlebotomy
Do not collect specimens

Are you seeking new testing that you haven’t ordered before?

Yes
No

Are you seeking laboratory testing that you have previously ordered?

Yes
No

Are you a phlebotomy company seeking to be added to our mobile draw network?*

Are you a phlebotomy company seeking to be added to our mobile draw network?

Yes
No

Are you setting up your account to order testing for yourself for a family member?*

Are you setting up your account to order testing for yourself for a family member?

Yes
No

Do you have an active client base that requires the testing you are seeking from DHA?*

Do you have an active client base that requires the testing you are seeking from DHA?

Yes
No

What is the average number of patients/clients you expect to order testing for in a given month?

Are there any specific tests you are seeking immediately?

Anything else that will help us set up your account to meet your needs?

How did you hear about us?

License

Upload License*

Max. file size: 50 MB.

I am not submitting a license for ordering purposes. I would like to request testing for wellness purposes

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License Uploaded Yes or No

yes
no

hidden field used for Infusionsoft automation

Phone

This field is for validation purposes and should be left unchanged.

Account Set-Up

General Information

Client Information

Additional Information

License

Have Questions? Contact us and we can help!