Onboarding - Discover Labs

Business and Primary Contact Information

Please provide the general business information. This is where the testing supplies will be sent.

Clinic Name *

Business Address *

Address Line 1

City

State

Zip Code

Primary Business Contact

The primary clinic contact is responsible for dealing with all administrative issues, including:
insurance information collection, full service testing scheduling, results reporting, etc.

Name *

First

Last

Phone Number *

Fax Number (For Patient Results) *

Email Address *

Clinic Contacts

Please enter the names, emails, and phone numbers for anyone at the clinic we might need to contact, as well as whether they will need access to results.

Name *

Email *

Phone *

Result Access?

Yes

Molecular Testing

Please answer with a numerical value of how many tests you will need processed per month.

How many COVID-19 tests per month?

Selected Value: 0

How many COVID-19 Reflex to RPP tests per month?

Selected Value: 0

How many FLUVID/RSV tests per month?

Selected Value: 0

How many Respiratory Pathogen Panel (RPP) tests per month?

Selected Value: 0

How many UTI/STI tests per month?

Selected Value: 0

How many Urinalysis Reflex UTI/C&S tests per month?

Selected Value: 0

How many Wound tests per month?

Selected Value: 0

How many Women's Health tests per month?

Selected Value: 0

How many Gastrointestinal tests per month?

Selected Value: 0

Shipping Information

This information is vital for a smooth testing process. Please assign one person at your facility who will be responsible for responsible for receiving Discover Labs supplies shipments.

Responsible faculty for receiving shipments is: * *

Same as primary clinic contact
A different person

Shipping address is: *

Same as clinic address
A different address

Additional Shipping Instructions

Please provide detailed shipping instructions to ensure all packages delivered to your clinic can be made available to our staff upon arrival. ie: Deliver to back door, no deliveries on Saturdays, etc.

Ordering Physician Information

The ordering physician is the physician prescribing the test.  
WE CANNOT TEST WITHOUT ACCURATE ORDERING PHYSICIAN INFORMATION.

Ordering Physician Name *

Ordering Physician NPI *

Ordering Physician Phone *

Ordering Physician Email *

Additional Comments?

Discover Labs Services

Business and Primary Contact Information

Primary Business Contact

Clinic Contacts

Molecular Testing

Shipping Information

Ordering Physician Information