New Account Registration Form

FACILITY INFORMATION

Facility Name *

Facility NPI#

Facility Address *

Facility City *

Facility State *

Facility Zip *

Facility Phone *

Facility Fax Number# *

Facility Primary Contact Name *

Facility Primary Contact Phone# *

Facility Primary Contact Email (One Email)*

ORDERING PROVIDERS:

For PATHOLOGY ONLY: If a provider wants a treatment recommendation report in addition to the GTI report, select either PharmD OR None.

Please note that you CAN NOT select both options for one provider. Only one can be selected.

PharmD None

Provider Name *

Provider NPI# *

Provider Email

Provider Phone

SERVICES NEEDED

LABXCHANGE: Will this account be utilizing LabXchange to submit online test orders? What is Labxchange? **PLEASE NOTE THAT NO LABXCHANGE SUPPLIES WILL BE SHIPPED IF THE ACCOUNT/STAFF HAS NOT BEEN TRAINED ON LABXCHANGE. Yes LabX No LabX

Pathology:

RPP/COVID

UTI

NAIL

GASTRO

WOUND

PGx

FLU/COV/RSV

TOXICOLOGY

MEDICATION MANAGEMENT

BLOOD

NEXT GEN SEQUENCING (NGS): Disclaimer: NGS testing often requires insurance prior authorization, and patients need to meet specific guidelines in order to qualify for testing

CARDIO/PULMO THYROID NEURO

Number of initial kits requested: **PLEASE NOTE LARGE QUANTITIES MAY REQUIRE APPROVAL

IMPORTANT: Supplies DO NOT need to be ordered separately for new accounts. The kits requested in this section will be shipped out (some may be subject to approval), and no additional steps need to be taken for supplies.

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 (Online portal credentials will be sent to this email): *

SPECIMEN PICKUP:

CALL/EMAIL TO SCHEDULE PICK UP AS NEEDED - Email Operations@GTILaboratories.com or call 480-646-8530

**Same day pick ups MUST be requested before 2:00pm in the client's time zone. This is subject to change depending on location.

ADDITIONAL NOTES / INSTRUCTIONS

Select this box if you do NOT want the Welcome Email sent to your client!!

GTI MANAGING SALES REPRESENTATIVE:

Name * Servicing/Managing Sales Representative (Primary Contact)

Email *

Phone

Affiliation/Group Name