New Account Registration Form

FACILITY INFORMATION

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.

SERVICES NEEDED



REPORT DELIVERY DESTINATION(S)

PLEASE PROVIDE A RESULT DESTINATION. **RESULTS CAN BE FAXED AND SENT TO THE ONLINE PORTAL

FEDEX PICK UP:

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

GTI MANAGING SALES REPRESENTATIVE:

GTI SUPERVISING SALES REPRESENTATIVES: