Facility Set-Up Form

Client*

Name

Client Site

Name

YesNo

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Fax*

Please enter a valid fax number.Format: (000) 000-0000.

Specialty

MolecularToxicologyPGx

YesNo

Drug Screen In-Office (POCT)Drug Screen at Lab (ILDP)

Provider Name and NPI*

Ordering Provider Signature Email

For physician signature

Name & Email for LIMS (Results through Portal)

PortalEmailFaxed

UPS Pick-Up

Lockbox Needed?

Staying on current placardEstablished UPS process currently in placePlacard Needed (Prearranged pickup times)

If PLACARD IS NEEDED, please fill out the information:

Main Contact

First NameLast Name

Phone Number

Please enter main contact phone number.Format: (000) 000-0000.

Email

Please enter main contact email.

Pick-Up Days and Times for PLACARD:

Please provide a 2-hour time frame alongside days of the week!

Sales Representative:

Any Additional Information?

Please contact facilities@ildp.com with any questions.