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Account Set-Up
General Information
Primary Interest
*
Primary Interest
Kryptopyrrole
Walsh/Pfeiffer Model Blood Testing
Routine Blood Testing
Laboratory
Other
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?
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?
Are you seeking new testing that you haven’t ordered before?
Yes
No
Are you seeking laboratory testing that you have previously ordered?
Are you seeking laboratory testing that you have previously ordered?
Yes
No
What is the average number of patients/clients you expect to order testing for in a given month?
What is the average number of patients/clients you expect to order testing for in a given month?
0-5
5-15
15-30
30+
Are there any specific tests you are seeking immediately?
Are there any specific tests you are seeking immediately?
Anything else that will help us set up your account to meet your needs?
Anything else that will help us set up your account to meet your needs?
How did you hear about us?
Upload License (Optional)
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License Uploaded Yes or No
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no
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Name
This field is for validation purposes and should be left unchanged.
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