Fill out this form to get a new account (physician, practice, hospital system) set up and ready to send samples.

Your Name *
Your Name
ex: Myrtle OBGYN
PRACTICE ADDRESS *
PRACTICE ADDRESS
PRIMARY CONTACT at the practice *
PRIMARY CONTACT at the practice
i.e. Head Nurse, Office Manager, Nurse Assistant
Primary Contact's Phone *
Primary Contact's Phone
PROVIDER #1 Name *
PROVIDER #1 Name
If the practice has more than 2 providers, please note additional providers’ details below.
*Note any special requests from the Practice* Share fax # if practice prefers fax communication.