Account Setup Information

Account Setup Information

Immunosciences Lab, Inc. 8693 Wilshire Blvd., Ste. 210, Beverly Hills, CA 90211
- Physician Name
  
  First NameLast Name
- Title(s)
- Facility Name
- Mailing Address
- City
- State
- Zip (Postal) Code
- Country
- Email
  example@example.com
- Phone
- Fax
- Contact Person
- NPI/UPIN
- Cardholder Name
- Exp. Date
- Security Code
- Billing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Cardholder Signature
- I certify that I have read ISL's Payment Policy Information. I agree to comply with the terms and conditions contained therein. I attest that I am currently licensed, by the state in which I practice, to order the laboratory testing offered by Immunosciences Lab., Inc.
- Attestation Signature
- Date
  
  MonthDayYear
  Date
- ISL Referral List
- Should be Empty: