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

ZIP Code

Fax No

Department Name

MedismartTreatment 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)

Preferred method of result notification :

Web PortalHIPAA 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): SMTWThFSat

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

RequsitionPOC TOX CupsAlcohol PadsGrey Urine Tubes
FEDEX AirbillSterile Urine CupsRed TubesTan Tubes
FEDEX Clinical Pak6x9 Biohazard BagsTiger TubesPurple Tubes
FEDEX Clinical Box21G Straight NeedleLt. Blue TubesH. Pylori Breath Bag
Foam Ice PacksTube Holder "Hub"Royal Blue TubesThinPrep Pap Kits
Fridge / FreezerTourniquetLt. Green TubesTablet PC
CentrifugePaper TapeGold TubesOral Fluid Tox
Phelbotomy Chair2x2 GauzeGrey Tubes

Pre-made Kits:

Blood

X

Toxicology

X

DNA

X

Pathology

X