Facility Set-Up Form

Client*

Name

Client Site

Name

Does the facility share medical records with other client sites?

YesNo

Is this client affiliated with another client?*

YesNo

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Fax*

Please enter a valid fax number.

Specialty

Type of Testing

MolecularToxicology

Screening Information with Toxicology:

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

Field Specialist Requested?

YesNo

Provider Name and NPI*

Ordering Provider Signature Email

For physician signature

Name & Email for LIMS (Results through Portal)

How do they want their results?

PortalEmailFaxed

Specimen Pick-Up

UPS Pick-UpCourier Route

If courier, provide the exact sample location, and if it is inside a building, please specify the building's closing time

Lockbox Needed?

UPS Pick-Up

Staying on current placardEstablished UPS process currently in placeQR Code needed (Scan when pickup needed)Placard 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.

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.

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