Provider Registration Form
Representative Group: DermaScape
Provider Name
*
First Name
Last Name
Practice Name / Company Name
*
Website
*
Business Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Provider Specialty:
Medical Doctor
Doctor of Chiropractic
Doctor of Osteopathy
PA
Naturopathic Doctor
Nurse Practitioner
Med Spa
Nutritionist
Telemedicine
Other
Available Credentials:
NPI Number, License Number, Other
Please upload a photocopy of the license(s) stated above.
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of
Potential Monthly Patient Volume of Genetic Testing:
New to Genetic Testing?
Yes
No
Interested In Private Labeling?
Areas of Interest in ExtendingMe US Services:
Foundational Panel
Longevity Panel Part One
Longevity Panel Part Two
Optimal Sleep Panel
Customized Diet Panel
Food Intolerance Panel
Dementia Risk Analysis
Metabolic Health Panel
Women's Health Panel
Epigenetics Panel
Preferred location of the Analysis Summary?
Beginning of report
End of report
Include Peptide Recommendations in the reports?
Yes
No
Do you want reports automatically released to patients when testing is complete?
*
Yes, automatically release reports to patients
No, I prefer to review results first
How would you like to share results with patients?
I will share reports using my existing system
Send patients an email with secure portal access to view their report
Do you want to review each patient's customized diet plan as part of the Customized Diet Panel?
Yes, notify me when I can review and edit the diet plan
No, generate the report using the laboratory-created diet plan
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