Harvest Labs - Setup Form

In an effort to provide the best service possible, we ask you to fill Form as completely as possible. Thank you for your cooperation!

1. Information

Section 1 of 4

Account Name *

Number of Locations

Representative

Preferred Contact Method

Call

Fax

Contact Information (Phone, Email, or Fax)

Sub Account

Portal User First Name*

Portal User Last Name*

Email*

Specialty

Phone*

( ) -

Fax*

( ) -

Shipping Address*

Building / Suite

City*

State*

Zip*

Clinician Name*

NPI #*

Clinician Name

NPI #

Clinician Name

NPI #

Clinician Name

NPI #

Total # of Clinicians

CLIA Waiver #

Report Delivery Method

Delivery Information

Pickup Days/Time*:

Monday

Tuesday

Wednesday

Thursday

Friday

2. Supplies

Section 2 of 4

3. Completed By Account Representative

Section 3 of 4

# of PCR / Month

PPO

HMO

Using POC (Point-of-Care) Cups?

Yes

4. Signature

Section 4 of 4

You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You further agree that each use of your E-Signature in obtaining an account with the Company constitutes your agreement to be bound by the terms and conditions of the Company's Terms of Service and Privacy Policy as they exist on the date of your E-Signature.

Name:

Date:

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