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Learn More about qPCR
Our Test Panels
Sexually Transmitted Infection (STI) Panel
Fungal Panel
Vaginitis Panel
Wound Panel
Respiratory Panel
Urinary Tract Infection (UTI) Panel
Mini Vaginitis Panel
Mini Respiratory Panel
PGx Panel
Shop Tests
Rep Login
Provider Login
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New Client
Onboarding Form
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Client/Account Name
Requested Start Date
FACILITY INFO
Facility/Clinic/Practice Name
Street Address
FACILITY TYPE
Primary Care
Specialist
Urgent Care
Rehab
SNF/ALF
Other
Suite
Other
City
State
Zip Code
Phone
Fax
FACILITY CONTACTS
Specimen Qty: 8
Primary Contact Name
Role/Position
Primary Email
Primary Phone
Practice Manager
Practice Manager Email
Practice Manager Phone
Billing/Accounts Payable Contact
Billing Email
Billing Phone
FACILITY PROVIDERS
Provider 1 Name
Provider 1 Type (APRN/PA/MD/DO):
Provider 1 NPI #:
Provider 1 Licensure State
Provider 2 Name
Provider 2 Type (APRN/PA/MD/DO):
Provider 2 NPI #:
Provider 2 Licensure State
Provider 3 Name
Provider 3 Type (APRN/PA/MD/DO):
Provider 3 NPI #:
Provider 3 Licensure State
Provider 4 Name
Provider 4 Type (APRN/PA/MD/DO):
Provider 4 NPI #:
Provider 4 Licensure State
Provider 5 Name
Provider 5 Type (APRN/PA/MD/DO):
Provider 5 NPI #:
Provider 5 Licensure State
SHIPPING / COURIER / PHLEBOTOMY
Specimen Pick-Up Required/Requested?
Yes
No
PICKUP DAYS
M
T
W
Th
F
Sat
Time (MUST INDICATE 1 HR WINDOW):
Time (MUST INDICATE 2 HR WINDOW):
Comments
*** COLORADO BASED CLINICS/FACILITIES ONLY ***
Courier Services Required/Requested?
Yes
No
Courier Services Days
M
T
W
Th
F
Sat
Courier Services Time (MUST INDICATE 1 HR WINDOW):
Courier Services Time (MUST INDICATE 2 HR WINDOW):
Phlebotomy Services Required/Requested?
Yes
No
Phlebotomy Services Days
M
T
W
Th
F
Sat
Specimen Priority Type:
STAT
ROUTINE
INTERNAL USE ONLY
Sales Representative:
Sales Email:
Sales Phone:
Next
COLLECTION SUPPLIES
MOLECULAR (PCR PANELS) COLLECTION SUPPLIES
Urine Collection Cups w/Transfer Tubes
Urine Collection Cups Volume:
Urine Collection Cups Qty:
Urine Collection Cups Date
Urine Specimen Hats
Urine Specimen Hats Volume:
Urine Specimen Hats Qty:
Urine Specimen Hats DATE:
Wound Swabs w/Tubes
Wound Swabs w/Tubes Volume:
Wound Swabs w/Tubes Qty:
Wound Swabs w/Tubes Date:
Vaginal Swabs w/Tubes
Vaginal Swabs w/Tubes Volume:
Vaginal Swabs w/Tubes Qty:
Vaginal Swabs w/Tubes Date:
Nasopharyngeal Swabs w/Tubes
Nasopharyngeal Swabs Volume:
Nasopharyngeal Swabs Qty:
Nasopharyngeal Swabs Date:
Cary-Blair Fecal (Stool) Swabs
Cary-Blair Fecal (Stool) Swabs Volume:
Cary-Blair Fecal (Stool) Swabs Qty:
Cary-Blair Fecal (Stool) Swabs Date:
SST (Serum Separator) Collection Tube
Specimen Tubes (Nail Clippings) Volume:
Specimen Tubes (Nail Clippings) Qty:
Specimen Tubes (Nail Clippings) Date:
TOXICOLOGY COLLECTION SUPPLIES
Toxicology Urine Collection Cups w/Transfer Tubes
Toxicology Urine Collection Cups w/Transfer Tubes Volume:
Toxicology Urine Collection Cups w/Transfer Tubes Qty:
Toxicology Urine Collection Cups w/Transfer Tubes Date
Urine Specimen Hats
Toxicology Urine Specimen Hats Volume:
Toxicology Urine Specimen Hats Qty:
Toxicology Urine Specimen Hats DATE:
Oral Fluid Collection Devices (Quantisal)
Oral Fluid Collection Devices (Quantisal) Volume:
Oral Fluid Collection Devices (Quantisal) Qty:
Oral Fluid Collection Devices (Quantisal) Date:
BLOOD (HEMATOLOGY/CHEMISTRY/IMMUNOASSAY PANELS) COLLECTION SUPPLIES
RED Top Collection Tube
RED Top Volume
RED Top Qty:
RED Top Date:
BLUE Top Collection Tube
BLUE Top Volume:
BLUE Top Qty:
BLUE Top Date:
Lithium-Heparin (GREEN Top)
Lithium-Heparin Volume:
Lithium-Heparin Qty:
Lithium-Heparin Date:
Sodium-Heparin (GREEN Top)
Sodium-Heparin Volume:
Sodium-Heparin Qty:
Sodium-Heparin Date:
PURPLE Top Collection Tube
PURPLE Top Volume:
PURPLE Top Qty:
PURPLE Top Date:
LAVENDAR Top Collection Tube
LAVENDAR Top Volume:
LAVENDAR Top Qty:
LAVENDAR Top Date:
Specimen Tubes (Nail Clippings)
SST Volume:
SST Qty:
SST Date:
Safety Winged (Butterfly) Needles (23 G)
Safety Winged Volume:
Safety Winged Qty:
Safety Winged Date:
Blood Collection Needle (21G)
Blood Collection Volume:
Blood Collection Qty:
Blood Collection Date:
Vacutainer Holder
Vacutainer Holder Volume:
Vacutainer Holder Qty:
Vacutainer Holder Date:
Tourniquets
Tourniquets Volume:
Tourniquets Qty:
Tourniquets Date:
Gauze/Roll Gauze/Alcohol Preps
Gauze Volume:
Gauze Qty:
Gauze Date:
GENERAL COLLECTION/SHIPPING SUPPLIES
Clinical Paks (Shipping Bags)
Clinical Paks Volume:
Clinical Paks Qty:
Clinical Paks Date:
Shipping Labels
Shipping Labels Volume:
Shipping Labels Qty:
Shipping Labels Date:
Specimen Bags
Specimen Bags Volume:
Specimen Bags Qty:
Specimen Bags Date:
Ice Packs
Ice Packs Volume:
Ice Packs Qty:
Ice Packs Date:
Next
MONTHLY VOLUME/PAYOR MIX
ANTICIPATED MONTHLY VOLUME – MOLECULAR (PCR) PANELS
UTI PCR Panel
UTI PCR Panel Volume:
Wound PCR Panel
Wound PCR Panel Volume:
STI PCR Panel
STI PCR Panel Volume:
Vaginitis PCR Panel
Vaginitis PCR Panel Volume:
Nail Fungus PCR Panel
Nail Fungus PCR Panel Volume:
Respiratory PCR Panel
Respiratory PCR Panel Volume:
GI PCR Panel
GI PCR Panel Volume:
PAYOR MIX
Medicare
Medicare Percentage
Medicare Advantage
Medicare Advantage Percentage
Medicaid
Medicaid PERCENTAGE::
Commercial PPO
Commercial PPO Percentage
Commercial HMO
Commercial HMO Percentage
Uninsured
Uninsured Percentage
ANTICIPATED MONTHLY VOLUME – OTHER TESTING (TOXICOLOGY/BLOOD)
Toxicology (Urine Drug Testing)
Toxicology (Urine Drug Testing) Volume
Blood (Core)
Blood Core Volume (copy)
PAYOR MIX
Medicare
Percentage 1
Medicare Advantage
Percentage 2
Medicaid
Percentage 3
Commercial PPO
Percentage 4
Commercial HMO
Percentage 5
Uninsured
Percentage 6
Next
Name 1
Phone 1
Email 1
Name 2
Phone 2
Email 2
Name 3
Phone 3
Email 3
Name 4
Phone 4
Email 4
Name 5
Phone 5
Email 5
Name 6
Phone 6
Email 6
Name 7
Phone 7
Email 7
Name 8
Phone 8
Email 8
Name 9
Phone 9
Email 9
Name 10
Phone 10
Email 10
Name 11
Phone 11
Email 11
Name 12
Phone 12
Email 12
Name 13
Phone 13
Email 13
Name 14
Phone 14
Email 14
Name 15
Phone 15
Email 15
Name 16
Phone 16
Email 16
Name 17
Phone 17
Email 17
Name 18
Phone 18
Email 18
Name 19
Phone 19
Email 19
Name 20
Phone 20
Email 20
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