NEW ACCOUNT SET UP FORM

NEW ACCOUNT SET UP FORM

CREDENTIAL REQUEST
Test kits and accounts are limited to credentialed healthcare professionals only, with the exception of Sports Panel. Please fill and submit this form electronically, or contact us if a PDF form to print out and scan is preferred. The account holder’s name must match the medical license/certification name provided.
Provider Name*

First NameLast Name
Practice Name*
Website*
Business Address*
City*
State*
Zip Code*
Phone Number*
Email Address*
example@example.com
Specialty / License*

MDDCDOPANDNPRDGym organization or athletic trainerOther
Credentials (NPI or Other License)*
Please upload a photo copy of the license(s) stated above*

Cancelof
Weekly Patient Volume (Average)*
New to Genetic Testing?*

YesNo
What are the other labs services you've previously used?
How did you hear about us? (Select all that apply)*

Search (Google, Bing)Social Media (Facebook, LinkedIn)Email MarketingReferralConference/WorkshopType option 6Other
Referral first and last name:
Sales Representative or Distributor that assisted you
Sales representative that assisted you
If "Other" Sales Representative is listed please provider their full name

Please note: Your card will be charged for the Welcome Kit Product once this form is submitted. Once your account is open a $15 credit will be applied to your account for future payments.

Welcome Kit FeeA $15 Credit will be added to your account for future ordering after your account is set up within 1-2 business days.

$15.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Fagron Genomics US Interests (Select all that apply)

Diet & Weight-Management (NutriGen)Athletic Performance (Sports Panel)Alopecia / Hair-Loss (TrichoTest)DNA / Biological Aging (TeloTest)Comprehensive NutriGenomics (Pro7)PharmacoGenomics (PGx)Methylation / Foundation / WellnessImmune / Auto-Immune / InflammatoryNeurological / PsychWomen's HealthMen's HealthDevelopmentalChronic PainNeurotransmitters / MoodGastrointestinalAutophagyDetoxificationPre-SurgicalTBI / Post-ConcussionEarly ChildhoodEssential VitaminsAll of the AboveUnsure / Don't Know YetOther
Signature*

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Date*

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Date
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