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LABORATORY CLIENT INTAKE FORM
Please fill out and return this form to allow for the creation of customized Laboratory Reports, Requisition Forms, and Client Portal access credentials.
LABORATORY / CLIENT NAME:
LABORATORY / CLIENT ADDRESS:
PHONE #:
FAX #:
CLIA ID:
LAB DIRECTOR:
POINT OF CONTACT (FIRST & LAST) NAME:
POC EMAIL & PHONE #:
Upload Laboratory Logo (Only 1 Logo)
SUBMIT FORM
