Establish Account

Clinic Information

Clinic Name:

Type of Clinic:

Address:

City:

State:

Zip:

E-Mail:

Phone:

Fax:

Clinic Hours:

DAILY PATIENT VOLUME:

NEW PATIENT PER YEAR:

NPI:

Transmission Type:

Default Report Type:

Client Bill:

Main Clinic Contact Information

First Name:

Last Name:

Position:

E-Mail:

Phone:

Collector Information

First Name:

Last Name:

EMR:

E-Mail:

Phone:

Sales Group/Rep Information

Salesmen Name:

Salesmen Phone:

Master Group Name:

Sub-Master Group Name:

E-Mail:

Address:

City:

State:

Zip:

Clinic Outreach Login

Clinic Login Email:

Preferred Password:

Order/Result Access:

CSS#:

Physician Login

Physician Name:

Physician NPI:

Physician UPIN:

Physician E-Mail:

Physician Phone:

Preferred Password:

Physician 2 Login Information

Physician Name:

Physician NPI:

Physician UPIN:

Physician E-Mail:

Physician Phone:

Preferred Password:

Physician 3 Login Information

Physician Name:

Physician NPI:

Physician UPIN:

Physician E-Mail:

Physician Phone:

Preferred Password:

Estimated Daily Test Options Counts

Urine Drug Confirmation:

Advanced Lipid Panel:

Genetics:

General Chemistry:

Allergy:

Respiratory Infection:

Hereditary Cancer Screening:

CGx:

Gastrointestinal Health:

Genetic Sequencing:

Flu A:

Flu B:

Payer Mix %

Medicare:

Medicaid:

Private:

Worker’s Compensation:

Cash:

Other:

Order Supplies

//MD Diabetes Pro //MD Allergy Pro

Test Options	QTY	UDM	Supplies
		KT	360666 MD DrugPro Starter Kit (Set of 20) 20EA PRE TNR HXK263 Specimen Cups, 20EA PRE LAB20609 Biohazard Bags, and 20EA PRE 5527 / 5528 False bottom tubes
		EA	PRE 101 Urine Req Form (20 EA)
		EA	345670 MD DrugPro Oral Fluid Collection Device (Set of 25)
		KT	360667 MD HeartPro Starter Kit (Set of 20) PRE 2017 HEART PRO Starter Kits, 10EA PRE 201F Blood coolers, 10EA PRE XB8 Ice packs, 20EA PRE LAB20609 Biohazard Bags, 60EA PRE 367988 SST tubes, 60EA PRE 367861 EDTA tubes, 20EA PRE 5528 / 5527 False Bottom Tube
		EA	PRE 102 Blood Req Form (20 EA)
		KT	MD DiabeticPro Starter Kit 2 sst tubes, 1 lav tuber, 1 urine sterile cup
		KT	362180 MD AllergyPro Starter Kit PRE 367988 SST Tubes 30EA, PRE LAB20609 Biohazard Bags 10EA, Blood Coolers 8” X 4 1/2” (355870), XB8 Ice Packs (356356) 5EA, 163032 UPS Lab Packs (353240) 5EA
		EA	365005 MD AllergyPro Req From (10 EA)
		KT	360671 MD GeneticPro PGx Starter Kit (Set of 10) PRE 2017 Genetic Pro Starter Kit 10 S-17208 white coin envelopes, 10 collection instructuins, 10 25-3306 Hydraflock sterile collection, 20 12-0500-00 DNA Stabilizing solution vials, 10 LAB20609 Biohazard Bag
		EA	359869 MD GeneticPro Req Form (10 EA)
		KT	MD GeneticPro RVBP and GI Panel Starter Kit (20 EA) RVBP Panel : E Swab (481C) 10EA, PRE LAB20609 Biohazard Bags 20EA, 10EA UPS Bags, 10 RVBP / GI Reqs GI Panel : G Swab (4C0245) 10EA, PRE LAB20609 Biohazard Bags 20EA, 10EA UPS Bags, 10 RVBP / GI Reqs
		EA	MD GeneticPro Hereditary Cancer Screening / CGx Starter Kit (Set of 10) PRE 2017 CGX Starter Kits 2EA 25-3606 Purflock 6” Swabs, 1EA PRE F20912 clear seal top bags, 1EA PRE P013590 silica gel packets (2 gram), 1EA PRE LAB20609 3-wall specimen bags ,1EA PRE P013590 self seal pouches, 1EA PRE 05160 White laser labels
		KT	MD GeneticPro HCV Panel 367988 SST Tubes (116986) 20EA, 235538 Biohazard Bags (341693) 10EA, Blood Coolers 8” X 4 1/2” (355870), XB8 Ice Packs (356356) 10EA, 163032 UPS Lab Packs (353240) 10EA, add 10 more MDHeart Pro Reqs
		KT	MD GeneticPro Women’s Health Panel Starter Kit (10 EA) E Swab (480C) 10EA, 235538 Biohazard Bags (341693) 10EA, 10EA UPS Bags
		EA	Covid 19 NP swab, Nares Swab, Saliva
		EA	Covid Sequencing NP swab, Nares Swab, Saliva
	New General Chemistry Account (Please Email Current Utilization Report to info@premedinc.com for Determination of Supplies Needed)