ACCOUNT SET UP FORM

Prior to any samples received, ACCOUNT SETUP FORM must be completed entirely or there will be delays in processing.

ACCOUNT SETUP FORM

Company or Facility Name*

Address*

Address 2

City*

State*

ZIP Code*

First Name*

Last Name*

Office Phone*

Cell Phone No*

Email*

First Name

Last Name

Office Phone

Cell Phone No

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

Rapid Covid-19 IGG/IGM

COVID-19

COVID-19 & RPP

COVID-19 with Reflex to RPP

other