New Account Registration Form | Genetic Technological Innovations

Facility Name: *

Facility NPI#:

Facility Address: *

Facility City: *

Facility State: *

Facility Zip: *

Facility Phone Number: *

Facility Fax Number#: *

Facility Primary Contact Name: *

Facility Primary Contact Phone#: *

Facility Primary Contact Email Address: *

ORDERING PROVIDERS:

Select the appropriate box to the left of the provider name to add the ARKSTONE, PharmD or Aegis report.
Please note that you CAN NOT select both options for one provider. Only one can be selected.

ARKSTONE

PharmD

Aegis (**This report is only available in select states – reach out to operations@gtilaboratories.com for the list of states)

None

Provider Name: *

Provider NPI#: *

Provider Email: *

Provider Mobile Phone:

SERVICES NEEDED:

Please select all that apply

PATHOLOGY:

RPP/COVID

UTI

NAIL

GASTRO

WOUND

PGx

WOMEN'S HEALTH

SURVEILLANCE PANEL

TOXICOLOGY:

URINE

MEDICATION MANAGEMENT:

URINE

NEXT GEN SEQUENCING:

NEURO

CARDIO

Number of initial kits requested:

Ship kits to: *

Address: *

REPORT DELIVERY DESTINATION(S):

PLEASE PROVIDE A RESULT DESTINATION. **RESULTS CAN BE FAXED AND SENT TO THE ONLINE PORTAL

Fax Number:

Email Address (Must be HIPAA compliant): *

FEDEX PICK UP:

CALL/EMAIL TO SCHEDULE PICK UP AS NEEDED - Email Operations@GTILaboratories.com for FedEx pick ups

DAILY/WEEKLY FEDEX PICK UP -

TIME: (Must be a 3 hour time frame)

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

**Same day pick ups MUST be requested before 2:00pm in the client's time zone. This is subject to change depending on location. If a recurring pick up is scheduled, FedEx requires that there be a package to pick up at LEAST 60% of the time. If the client does not meet those standards, the recurring pick up will be cancelled.

GTI MANAGING SALES REPRESENTATIVE **Please notate below if this account has a sub-representative

Name: *

Sub-Rep Name:

Email: *

Sub-Rep Email:

Phone: *

Sub-Rep Phone: