901 NorthPoint Park Way, Suite #120
West Palm Beach, Fl 33407
Office:(888)692-7508
[email protected]
Company
Information
CLIENT
REGISTRATION
FORM
Business Name:
Date:
Sales Rep:
Address:
City:
State:
Phone #:
Fax #:
Zip Code:
Clinical Contact
Name:
Email:
Title:
Phone #:
Billing Contact
Name:
Title:
Phone #:
City:
State:
Zip Code:
Thurs:___
Fri:___
Billing Information (If Different Than Above):
Business Name:
Address:
Phone #:
Fax #:
Email:
Logistics and Reporting
□ FedEx
□ Courier
Reporting/Delivery options:
Mon:___
□ Online
Tues:___
□ EMR Interface
Wed:___
□ E-mail
□ Fax
Additional Instructions/Notes:________________________________________________
Expected Number of Monthly Specimens
Urine: _______
Blood: _______ PGX: ________
Physician Section
This Section authorizes Ozark Laboratories to test each specimen according to the selections made on the individual laboratory
requisition or online ordering portal. Please have ordering physician(s) complete the four boxes below.
Physician Name:
Physician NPI #:
Physician's Signature:
Date: