Reference Lab Interface Request Form
Requesting Laboratory Information
Laboratory Name
*
Laboratory Contact Name
*
Lab Contact E-mail
*
You will receive a confirmation email for your request at this email address
Are you a Labgen Client?
*
No
Yes
LIS Information
LIS Company Name
*
LIS Technical Contact Name
*
LIS Technical Contact Email
*
example@example.com
Ordering Lab Or Resulting Lab
Are you the Ordering Lab or the Resulting Lab?
*
Ordering Lab
Resulting Lab
Please provide the Labgen Client Number for the Ordering Lab
*
Lab Info
Ordering Lab Details
Please Enter Information About the Ordering Lab
Resulting Lab Details
Please Enter Information About the Resulting Lab
Laboratory Name
*
Laboratory Contact Name
*
Laboratory Contact Email
*
example@example.com
LIS Information OTHER LAB
LIS Company Name
*
LIS Technical Contact Name
*
LIS Technical Contact Email
*
example@example.com
Interface Details
Interface Details
Interface Type
*
Please Select
Bi-Directional
Uni-Directional (Orders Only)
Uni-Directional (Results Only)
Who will be covering the DEVELOPMENT cost of the interface?
*
Who will be covering the YEARLY MAINTENANCE cost of the interface?
*
Comments
Reply to Email
Submit
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