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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
Shop Tests
Rep Login
Provider Login
Contact Us
New Client
Onboarding Form
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2
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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
FACILITY CONTACTS
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
Provider 1 NPI #:
Provider 1 Licensure State
Provider 2 Name
Provider 2 Type
Provider 2 NPI #:
Provider 2 Licensure State
Provider 3 Name
Provider 3 Type
Provider 3 NPI #:
Provider 3 Licensure State
Provider 4 Name
Provider 4 Type
Provider 4 NPI #:
Provider 4 Licensure State
Provider 5 Name
Provider 5 Type
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
Client/Account Name 2
Requested Start Date 2
COLLECTION SUPPLIES
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 Top Qty:
Lithium-Heparin Top Date:
Sodium-Heparin (GREEN Top)
Sodium-Heparin (GREEN Top) Volume:
Sodium-Heparin (GREEN Top) Qty:
Sodium-Heparin (GREEN Top) Date:
PURPLE Top Collection Tube
PURPLE Top Collection Tube Volume:
PURPLE Top Collection Tube Qty:
PURPLE Top Collection Tube Date:
LAVENDAR Top Collection Tube
LAVENDAR Top Collection Tube Volume:
LAVENDAR Top Collection Tube Qty:
LAVENDAR Top Collection Tube Date:
SST (Serum Separator) Collection Tube
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:
Sharps Container
Sharps Container Volume:
Sharps Container Qty:
Sharps Container Date:
MOLECULAR (PCR PANELS) COLLECTION SUPPLIES
Urine Collection Cups
Urine Collection Cups Volume
Urine Collection Cups Qty:
Urine Collection Cups Date:
Urine Transfer Tubes w/Straw
Urine Transfer Volume:
Urine Transfer Qty:
Urine Transfer 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:
Nasopharyngeal Swabs w/Tubes
Nasopharyngeal Volume:
Nasopharyngeal Qty:
Nasopharyngeal Date:
Cary-Blair Fecal (Stool) Swabs
Cary-Blair Fecal Swabs Volume:
Cary-Blair Fecal Swabs Qty:
Cary-Blair Fecal Swabs Date:
Specimen Tubes (Nail Clippings)
Specimen Tubes Volume:
Specimen Tubes Qty:
Specimen Tubes 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:
Requisition Forms
Requisition Forms Volume:
Requisition Forms Qty:
Requisition Forms Date:
Next
MONTHLY VOLUME/PAYOR MIX
Specimen Volume: Clinical
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: (copy)
Vaginitis PCR Panel
Vaginitis PCR Panel Volume:
Nail Fungus PCR Panel
Nail Fungus PCR Panel Volume:
Respiratory PCR Panel
Respiratory PCR Panel Volume:
PAYOR MIX
Medicare
Medicare Percentage
Medicare Advantage
Medicare Advantage Percentage
Medicaid
Medicaid
Commercial PPO
Commercial PPO Percentage
Commercial HMO
Commercial HMO Percentage
Uninsured
Uninsured Percentage
ANTICIPATED MONTHLY VOLUME – OTHER TESTING (BLOOD)
Blood (Core)
Blood Core Volume
PAYOR MIX
Medicare
Percentage
Medicare Advantage
Percentage
Medicaid
Percentage
Commercial PPO
Percentage
Commercial HMO
Percentage
Uninsured
Percentage
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