Physician Account Registration





Date:    Acct Rep Name:

Phone:    Group Name:

Acct Rep Email:


Facility Name:



Address:


Main Clinic Contact Name:


Address Cont.:


Email:


City, State:


Days & Hours of Operation:


Zip Code:


Phone Number:


Fax Number:


PROVIDER NPI NUMBER
PROVIDER NPI NUMBER



Final Reporting


 Physician Approval - Billing Dept. to Contact Patients

Final Reporting for Toxicology:  Faxed      Web Portal

Need UPS Pickup?  Yes      No

Admin Use

Start Date:

UPS Notified:

Supplies Shipped:

Lab:

WebPortal UN:

PWD:


Notes

SUPPLY REQUEST
PLEASE FAX TO: (866) 531-1977

QUANTITY
ITEM


Point of Care Cups (multiple of 25)
Temperature (transport) Cups
Oral Swabs (multiple of 5)
Specimen Bags
Requisition Forms
UPS Lab Packs
UPS Boxes (multiple of 10 or 20)
UPS Shipping Labels
Billing Rack Cards
Plexi Rack Card Holder
Presentation Folder (For Marketing only)
Med Monitoring Brochure (For Marketing only)



Shipment Date:

Facility Name:

Mail Attention To:

Address:

WebPortal UN:

Ship:  Next Day Air (overnight)  Ground

For Admin Use:  Submitted By:  Filled By:


Custom Profile

Facility Name:

Immunoassay Screen

Barbiturate

Cotinine

Ethanol

Ethyl Glucuronide

K2/Synthetic Cannabinoids

LC/MS Confirmation

Opiates & Synthetic Opioids

Buprenorphine

Buprenorphine w/ Naloxone

Codeine

Fentanyl

Hydrocodone

Hydromorphone

Meperidine

Methadone

Morphine

Naloxone

Naltrexone

Oxycodone

Oxymorphone

Pentazocine

Propoxyphene

Tapentadol

Tramadol

LC/MS Confirmation

Stimulants

Amphetamine

Methamphetamine

Methylphenidate

Phentermine

Benzodiazepines

Alprazolam

Clonazepam

Diazepam

Estazolam

Flunitrazepam

Flurazepam

Lorazepam

Midazolam

Nordiazepam

Oxazepam

Temazepam

Muscle Relaxants

Carisoprodol

Cyclobenzaprine

Meprobamate

Nonbenzodiazepine Hypnotics

Zaleplon

Zolpidem

Zopiclone

LC/MS Confirmation

Behavioral

Amitriptyline

Desipramine

Doxepin

Imipramine

Nortriptyline

Protriptyline

Quetiapine

Trazodone

Illicit

Bath Salts

Cocaine

Heroin (6-MAM)

PCP

Marijuana

Other

Gabapentin

Ketamine

Pregabalin

Primidone

Mitragynine

Phenazepam


Please select tests to be included in your custom profile. — Immunoassay Screens are qualitative, LC/MS Confirmations are fully quanlitative.

 I request the above predefined custom profile to be performed on all my patients. I understand that I will have the ability to individually redefine this test profile on patient requisition forms.

 I wish to order solely from the individual patient requisition forms.


Physician Printed

Physician Signature


Date