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
Reset Primary Email
Delete
CLIENT INFORMATION
Facility Name
Phone
Address
Address 2
City
State
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Fax No
Department Name
Medismart
Treatment Center
Generate Auto Accession
Assign Sales Rep
Select
Blake Crockett
Bryan Test
Dawn Kuipers
Evelyn Yang
hamna test
Mercy Crisostomo
Test Waleed Test Waleed
Add Deparment
Add Location
CONTACT INFORMATION
Primary Contact Name
Title
Primary Contact Phone
Email
(Associated with Web Portal Log-in)
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
Yes
No
Collector
Phlebotomist
None
Need to transfer existing office staff to Fida ?
Yes
No
How Many
Star Time
Start Date
Payrate
Specimen Pickup Information
 
COURIER
FEDEX
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
Select
25
50
100
200
500
Toxicology
X
Select
25
50
100
200
500
DNA
X
Select
25
50
100
200
500
Pathology
X
Select
25
50
100
200
500