To sign up for a new account, please complete the following online form.

Physician/Group Name:
Lab Assigned Acct#:
Street Address:
City:
State/Province:
Country:
Zip/Postal Code:
Phone:	(include area code)
Fax:
Email Address:
Name of Physician #1:
UPIN #:
NPI #:
Medical Specialty:
Name of Physician #2:
UPIN #:
NPI #:
Medical Specialty:
Name of Physician #3:
UPIN #:
NPI #:
Medical Specialty:
Contact Person:
Office Hours:	Mon Tues Wed Thurs Fri
Type of Specimens to be Sent:
	Frequency
Complete Reading/Diagnosis:	/Day /Week /Month
Consultation with Prepared Slide OPD Slide Preparation:	/Day /Week /Month
X Required # of Slide(s) /Each Block :	/Day /Week /Month
I would like to set up an account: Yes No
Type of Billing (Check as Many as Apply)	Private Insurance Patient Physician Private Medicare
Comments: