ACCOUNT SET UP FORM

Prior to sending any samples, you need to complete the Account Set Up Form below, or there may be a delay in processing.

ACCOUNT SETUP FORM

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CLIENT INFORMATION

Facility Name

Phone

Address

Address 2

City

State

ZIP Code

Fax No

Department Name

Medismart

Treatment Center

Generate Auto Accession

Assign Sales Rep

Add Deparment

Add Location

CONTACT INFORMATION

Primary Contact Name

Title

Primary Contact Phone

Email (Associated with Web Portal Log-in)

Please enter correct format

Preferred method of result notification :

Web Portal

HIPAA Fax #

Both

Rep contact info :

Physician Last Name*

NPI# *

Physician First Name*

PHYSICIAN SIGNATURE:

Add Another Physician

SHIPPING INFORMATION

Requesting FedEx reoccurring pick up ? Yes NO (If no,please disregard the following 3 lines)

Preferred pick up time (Note 2 hours window)

Close of business time:

Location of pick up (Front door, reception desk, etc.):

Requested pick up date(s):

S

M

T

W

Th

F

Sat

Additional notes

Need to hire new staff

YesNo

Collector

Phlebotomist

None

Need to transfer existing office staff to Fida ?

YesNo

How Many

Star Time

Start Date

Payrate

Specimen Pickup Information

COURIERFEDEX

Pickup Time Requested:

Supply Needs for Client

Requsition	POC TOX Cups	Alcohol Pads	Grey Urine Tubes
FEDEX Airbill	Sterile Urine Cups	Red Tubes	Tan Tubes
FEDEX Clinical Pak	6x9 Biohazard Bags	Tiger Tubes	Purple Tubes
FEDEX Clinical Box	21G Straight Needle	Lt. Blue Tubes	H. Pylori Breath Bag
Foam Ice Packs	Tube Holder "Hub"	Royal Blue Tubes	ThinPrep Pap Kits
Fridge / Freezer	Tourniquet	Lt. Green Tubes	Tablet PC
Centrifuge	Paper Tape	Gold Tubes	Oral Fluid Tox
Phelbotomy Chair	2x2 Gauze	Grey Tubes

Pre-made Kits:

Blood

X

Toxicology

X

DNA

X

Pathology

X