Provider Registration Form
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
Do you want reports automatically released to patients when testing is complete?
Yes, automatically release reports to patients via the secure patient portal
No, I prefer to review results first
Once reviewed, 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
Submit
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