NEW CLIENT ONBOARDING FORM We Welcome You SUBMITTED BY Name * First Name Last Name CLIENT ACCOUNT ONBOARDING COMPLETED BY Name * First Name Last Name CLIENT ACCOUNT NUMBER ASSIGNED Client Account Number Assigned * PHYSICIAN INFO Name * First Name Last Name Title * Physician NPI: * Physician Taxonomy Code * Address * (Address associated with NPI number only) Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Fax (###) ### #### Email * MAIN CONTACT PERSON INFO Name * First Name Last Name Title * Phone * (###) ### #### Fax (###) ### #### Email * FACILITY INFO Full Name of Facility * Check here if address is same as Physician above Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Fax: (###) ### #### Email * Website * http:// Office Hours * TYPES OF SPECIMENS Types of Specimens (Check all that apply): * Pathology Specimen Cytology (including Thinprep GYN/Rectal) Thinprep (GYN/Rectal) for PCR testing high risk HPV including high risk genotyping, CT/GC and T. vaginalis Nasopharyngeal/Nasal Swab (COVID) Oropharyngeal Swab (HPV) & CT/NG Stool in Cary/Blair for Multiplex Gastrointestinal Panel Thank you!
