Client Offboarding Initiation
Submitters Name:
*
First Name
Last Name
Submitters Email:
*
Account Number:
*
Account Name:
*
When will be the last day client needs Mako services?
*
-
Month
-
Day
Year
Is the offboarding being initiated by the client or Mako?
*
Client
Mako
What are the reasons for the offboarding?
*
Account Lost to Another Laboratory
Mako Unable to Provide Client's Desired Services
Service Failures
Unprofitable Account
Other
What lab will be providing services to the client moving forward?
*
LabCorp
Quest
Unknown
Other
Is there an EMR integration to off-board?
*
Does the account have scheduled MAKO Courier?
*
Yes
No
Is there a PSR to off-board?
*
Yes
No
What is the Name of PSR to off-board?
*
First Name
Last Name
Are there outstanding invoices?
*
Yes
No
Are there any IT assets?
*
Yes
No
Select the type of asset:
*
Dymo Printer
Desk Printer
Laptop
Are there any large supply items (centrifuge, phlebotomy chair, refrigerator, etc)?
*
Yes
No
Large Supply Items:
Submit
Should be Empty: