Early Adopter Application

Are you a clinician or a clinic employee?*

YesNo

Are you a longevity medicine clinic employee?*

YesNo

Thank you for your interest. However, SapereX is only available through qualified longevity clinics. Let us know a little about you and we'll be in touch about future testing opportunities.

Do you have longevity medicine clients?*

Yes. I'm managing a cohort of longevity medicine clientsNo. My patient care is not focused on longevity

Is your longevity medicine clinic in the United States?*

YesNo

Thank you for your interest. We are excited about future opportunities to work with global longevity clinics. However, at the current time, SapereX is only available in the United States.

Let us know a little about you and we'll be in touch about future testing opportunities.

Does your longevity clinic have in-house phlebotomy?*

YesNo

SapereX testing requires venipuncture. The blood draw cannot be performed at a third party facility, e.g. Labcorp or Quest. Let's set up your account and a member of our team will reach out to discuss solutions that will ensure the integrity of testing.

Is your clinic located in NY or CA?*

YesNo

Laboratory certifications for NY and CA take a little extra time. Let's set up your account and we'll contact you as soon as the requirements in your state have been met.

Your First Name*

Your Last Name*

Title

Email*

Clinic Name*

Clinic Website

Location

Street Address

Street Address Line 2

CityState / Province

Country

Global Clinic Location*

Street Address

Street Address Line 2

City

Country

Please provide information about at least one clinician authorized to order*

	Ordering Physician 1	Ordering Physician 2	Ordering Physician 3
Name
Degree(s)
Board-certified specialty
License #
State
NPI#

Please provide information about at least one other authorized contact*

	Ordering/Payment	Sample Collection	Reporting
Name
E-mail

Please provide a single e-mail address that can be used as a login to access your customer portal for ordering, sample submission, and resources.

Email for SapereX portal login*

Anything else you'd like us to know

e.g. clinic e-mail for labs, people to copy on reports, etc.

Do you have an affiliate clinic in the US?

YesNo

US clinic name and nature of relationship

Tell us why you're excited about cellular senescence and immune function testing

Testing volume anticipated in one year

Years in business

How do you typically describe your clinic? (select all that apply)

Other Clinic Descriptor