New Account Setup Form

New Account Setup Form

Please make sure to fill in the required fields and submit this form to complete your order.
Providers:*
Office Contact Information:
Contact Name*

First NameLast Name
Practice/Clinic Name (Optional)
Provide Email and/or Office Contact Number:
E-mail*
example@example.com
Office Contact Number
Fax Number (Optional)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Hours*

Order Type:

IBS100 (In-Office Collection)TMEDIBS (Telehealth - Kit Mailed to Patient)
Additional Information:
Additional Results Access Users:
inFoods IBS Prepaid Shipping Labels for Sample Collection Kits

10 Preprinted USPS Labels: 2-Day Priority, 1.0 lb, from address above to Ethos
Ship Initial Labels To:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Office Contact Information: