Account Onboarding

Practice Name*
Does this Practice have multiple locations/clinic sites?*

YesNo
Facility/Client Site
Territory Manager*
Specialty*

Primary CareUrgent CarePediatric CareNursing / RehabilitationSurgeryOther
Clinic Address*

Street Address

Street Address Line 2

CityState

Zip Code
Clinic Phone Number*
Secure Fax Number
Please enter a valid phone number.
Hours of Operation*

Hour Minutes

AM/PM Option

until
until
Hour Minutes

AM/PM Option
Days of Operation*

MonTuesWedThursFriSatSun
Time Zone*

CST - CentralEST - EasternMST - MountainPST - Pacific

Patient Estimate*

	Per Week	Per Month
Total NEW Patients
Total RECURRING Patients

Report Delivery Preference

Online PortalAutomatic Fax
Check the box below to exclude preliminary reports from automatic faxes

Exclude Preliminary Reports (If selected, only FINAL reports will be faxed to clients.)
Facility EMR System
Laboratory Location/Utilization (Select all that apply)

Mobile, ALBaton Rouge, LA

Clinic Contact #1*
First and Last Name
Email*
example@example.com
Check the box below to grant authorization for portal access

Authorize Portal Access
Clinic Contact #2
First and Last Name
Email
example@example.com
Check the box below to grant authorization for portal access

Authorize Portal Access
Clinic Contact #3
First and Last Name
Email
example@example.com
Check the box below to grant authorization for portal access

Authorize Portal Access

New Account Registration