Physician/Client Inquiry Meeting Form

Info/Meeting Form

We will get in touch with you shortly to confirm
Company Name*
Name of your business
Company Address*

Street Address

Suite #

CityState / Province

Postal / Zip Code
Contact Person Name*

First NameLast Name
Contact Person Title*
Contact Person Phone Number *
Contact Person E-mail *
Is Your practice and physicians credentialed with CMS and PECOS?*

YesNo
How long has your company been in operation?*
How many physicians/practitioners are at your practice?*
What's your company's specialty:*
Urology, OBGYN, Geriatrics...etc..
Type of Company:*

Medical ClinicNursing FacilityHome Health AgencyOther
Do any physicians at your practice see patients at assisted Living Facilities?*

YesNo
What type of nursing facility are you?*

Assisted LivingGroup Home
How many residents live at your facility?*
Number of beds at your facility
Please list the number of days per week you're needing services:*
How are labs ordered at your facility?*

Medical Director (All labs are ordered for every resident via one Physician)Multiple physicians (Each resident has their own Individual physicians)Other
How many physicians order labs at your facility?*
List the number of physicians that order/work in your facility
What lab do you currently use to run your Residents/Patients specimens?*

Sonora QuestLabCorpOther
What EMR system do you use?*
Please type N/A or none if you currently don't use an EMR
What is your company's biggest frustration/problem with your current lab setup?*
Are you ready to switch from your current Diagnostic Lab:*

YesNoOther
How soon are you wanting to switch to our lab services?*
Services your interested in:*

Laboratory Testing only (you have a person to collect specimens in office or don't need mobile collections)Laboratory Testing with mobile specimen collections
All clients may potentially become eligible for complimentary mobile phlebotomy services for their patients following a 90-day review of their laboratory service usage.
What Area/Region/County are most of your patients located?*
Specimen Volumes
Blood Tests Per Month: (Standard routine tests)*

0255075>100
Molecular Tests Per Month: (RPP, UTI/STI, Wound, Toenail, Woman's Reproductive Health, GI)*

0255075>100
Toxicology Tests Per Month: (Drug level Testing)*

0255075>100
Women's Health Testing Per Month: (Paps etc.)*

0255075>100
Genetics Tests Per Month:*

0255075>100
Overall specimens per month:*

50-100 patients101-200 patientsOver 200 patients a month
Types of tests/panels ordered frequently at your practice:*
Types of insurances frequently ran at your practice:*
Schedule A Video Meeting :*
Should be Empty:

Info/Meeting Form

Specimen Volumes