Client Profile

* = required field Download form here

Client Information:

Date:

Clinic Name: Specialty:
Address:
City: State/Province:
Zip/Postal Code:
Phone: Fax:
Clinic Contact Name:
Contact Email:

Physician Information:

Physician Name:* License #:*
Medical Designation (i.e. M.D., FRCS., PhD., etc):*
Phone:* Fax:
Contact Email:*

Specimen Collection
A minimal sample collection from the Nasopharynx is required in order to process the NPScreen™ test optimally and properly. Upon arrival of the sample at the laboratory, an assessment of the sample adequacy will be performed. If the sample received is deem insufficient for further analyses, the laboratory will issue a request to the sending physician for re-collection of sample from the said patient for further testing.

Billing Policy
I hereby acknowledge that I will provide complete and accurate patient demographic information for proper identification of the NPScreen™ sample for processing. My account will be held responsible for all charges associate with each NPScreen™ test directly; or indirectly via the agency.


Account Agency: Representative Name:

Privacy Policy
The information provided is used strictly for proper identification of patient data only. The information is available to the requesting/responsible physician via their private login for viewing of the results of the said patient only. The patient has the right to access and correct his/her personal data via the responsible physician or clinic login system.

captcha (Enter the characters shown below)

Reset

Back to Top