ACCOUNT ENROLLMENT – LOR Diagnostics

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Shipping supplies (to set up a pickup, regardless of label type, please visit our pickup request page

Are you*

Legal Name:*

Type of practice/facility:*

Address*

Street Address Address Line 2 City State ZIP Code

Contact Name:*

Contact Email (For portal access, list if multiple):*

Contact Phone Number*

Fax Number:*

Multiple locations*

Yes

Add Multiple locations*

Address:

Contact Name:

Contact Email:

Phone Number

Fax Number:

EMR Name:*

Office Manager Name:*

Office Manager Email:*

Physician Details:*

Physician Legal Name:

Credential Abbreviation:

NPI:

Implementation Date*

LOR Representative placing order*

LOR Representative Email:*

Person placing order:*

Email for order updates:*

Kit Dispenser Box*

Yes

UPS Placard Program*

Yes

# of UPS Labels*

# of FedEx Labels*

# of Shipping Bags*

Kits*

Quantity

KIt Type

Notes

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