AML Account Agreement

Account Agreement

Please fill out this form to open an account.
Are you an existing Provider with Alletess Medical Laboratory?*

YesNo
Are you a Phlebotomist or Blood Draw Site?*

YesNo
Do not fill out this form.

Phlebotomists do not need to fill out an Account Agreement

Please visit:

https://form.jotform.com/221978399799082
If you just need to order additional test kits, please call Customer Service at 800-225-5404 and we will be happy to assist you.

If you have moved or not used Alletess for two or more years, please proceed and fill out a new Account Agreement.
Provider Name*

Provider First NameProvider Last Name
Professional Degree*
Medical Specialty
NPI#
State License Issued*
Professional License #
We do not offer service to offices in the state of NY
Clinic Website
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Business Name*
Fax No.
Clinic Address (Please note: this is the address that will appear on the test result)*

Street Address

Street Address Line 2

City / TownState

Zip Code
Bill State*
State
Is Shipping Address same as Clinic Address ?*

YesNo
Shipping Address*

Street Address

Street Address Line 2

City / Town

Zip Code
Ship State*
State
Accounts Payable Dept. Contact*

First NameLast Name
Accounts Payable Phone Number
Please enter a valid phone number.
Accounts Payable Email*
example@example.com
Best Office Contact Name (Office Manager, MA, etc.)*

First NameLast Name
Office Contact Phone
Office Contact Email*
example@example.com
Collection Test Kits Requested:
Additional test kits can be ordered through the clinicians portal on our website, www.foodallergy.com, by fax or phone (800-225-5404).
Serum Kits (Requires blood draw, can run all tests)

2x Serum Test Kits (Requires blood draw) (Can run all tests)
Finger Stick Kits (No blood draw, can run all food sensitivity tests, Candida IgM)

2 x Finger Stick Kits
Test Result Delivery*

Electronic PDF: Clients will be emailed when test results are released and available for download through ShareFile, a secure, cloud-based, HIPAA compliant platform.Fax
Fax No.*
List result notification contact and email address(es):
Contact and Email*

First NameLast Name
Result Notification Email*
example@example.com
Payment Options: Please choose a preferred option*

Patient Prepay: Payment must be submitted with the sample.Bill to Clinician: Mastercard, Visa, or Discover. Your CC will be charged to establish credit on receipt of the first sample. You will be invoiced monthly thereafter. If you select this option an account representative will contact you for credit card information.
Payment Terms

Prepay OnlyBill To Doctor
Card Details:
Signature

Clear
Have you previously ordered testing from Alletess Medical Laboratory?*

YesNo
Please tell us how you heard of Alletess Medical Laboratory*

PatientOnline SearchColleagueConference/Seminar
Name of Colleague
Name of Conference/Seminar
I confirm that I, the provider*
(Print name) meet all state licensure requirements and am authorized to order clinical laboratory testing.
Provider's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Account Agreement

We do not offer service to offices in the state of NY

Collection Test Kits Requested:

List result notification contact and email address(es):

Card Details: