GTI Laboratories

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)*

Critical Contact Name *

Critical Contact Email

Critical Contact Phone

ORDERING PROVIDERS:

PharmD treatment recommendation report: (PATHOLOGY TESTING ONLY)

Aegis PharmD No PharmD

Provider Name *

Provider NPI# *

Provider Email

Provider Phone

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

New Account Registration Form

FACILITY INFORMATION

ORDERING PROVIDERS:

SERVICES NEEDED

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.

RPP/COVID

UTI/STI/NAIL/GASTRO/WOUND (universal collection device)

TOXICOLOGY

MEDICATION MANAGEMENT

BLOOD STARTER KIT

PHARMACOGENETICS (PGx)

LABXCHANGE: Will this client be utilizing our barcode electronic ordering system?

REPORT DELIVERY DESTINATION(S)

SPECIMEN PICKUP:

GTI MANAGING SALES REPRESENTATIVE:

GTI SUPERVISING SALES REPRESENTATIVES: