New Account Registration Form | Genetic Technological Innovations

 

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New Account
Registration Form

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.


SERVICES NEEDED:

Please select all that apply

LABXCHANGE: Will this account be utilizing LabXchange to submit online test orders?

**Please note that the account will need to be trained on how to use LabXchange before being sent barcoded supplies.

PATHOLOGY:
TOXICOLOGY:
MEDICATION MANAGEMENT:
NEXT GEN SEQUENCING:

REPORT DELIVERY DESTINATION(S):

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

FEDEX PICK UP:

**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