ACCOUNT SET UP FORM

Prior to any samples received Account Set Up Form must be completed in its entirely ,or there will be a delay in processing.

Select Account Type

Please select one of the following options

Healthcare providers

Pharmacy

Facility

CONTACT INFORMATION

Location ID*

Critical Contact Details

Critical Contact Name*

Critical Contact Phone Number*

Critical contact Email*

Pharmacist / Ordering Practitioner Details

Pharmacist / Ordering Practitioner Email *

Pharmacist / Ordering Practitioner Full Name*

NPI# *

NCPDP #

SHIPPING INFORMATION

UPSFEDEX

Pickup Time Requested:

Requested pick up date(s):

Files

File	Date/Time	Delete