NEW CLIENT INFORMATION FORM
Account Representative
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Practice Name
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Start Date
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Month
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Day
Year
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Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Practice Address (Address, City, State, Zip)
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Phone Number
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Fax Number
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Emergency/Internal #
Physician A (Name/UPIN/NPI)
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Physician B (Name/UPIN/NPI)
Physician C (Name/UPIN/NPI)
Physician D (Name/UPIN/NPI)
Main Contact Person (Name/Title/Number)
Office Hours
*
Phlebotomist (Name/Number)
CLIA LICENSE REQUIRED
Yes (Has Our Phlebotomist)
Yes (Is a Draw Station)
No (Just Picking Up)
Report Deliver Format
Paper
Web
Fax
Prelims and Finals
Finals Only
Report Style Requirements
Standard
Cumulative
Custom (Call Lab)
Requisition Requirements
Standard
Custom (Call Lab)
Custom Panel A
Custom Panel B
Custom Panel C
Custom Panel D
Computer Requirements
CPU
Monitor
Printer
Label Printer
Fax Machine
Fax Line
Internet Line (DSL)
Computer Desk
Patient Pricing
Please Select
Standard Patient Pricing
Discounted Patient Pricing
Custom Patient Pricing (Attachment Required)
Attach: Price List
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Attach: Panic Values List
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Attach: Requisition
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Picture of Computer Install Location
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Additional Information
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Your Email Address
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