New Client Registration Form

Date:

Salesperson Name:

1. Practice / Facility Information

Practice Name:

Address:

City:

State:

ZIP:

Phone:

Fax:

Email:

2. Provider Information

Primary Provider Name:

NPI #:

Provider 2 Name:

NPI #:

Provider 3 Name:

NPI #:

Provider 4 Name:

NPI #:

3. Courier and Logistics

Preferred Pickup Times:

Days of Operation: Mon Tue Wed Thu Fri Sat

Courier Services: Local Courier Pickup UPS Daily Pickup UPS - Call In

4. Agreement

By signing below, the provider or authorized representative of the medical practice agrees to submit patient specimens to Clinical Diagnostic Laboratory (CDL) for diagnostic testing and acknowledges the following:

CDL will provide accurate and timely test results to the ordering provider.
CDL will supply all necessary specimen collection materials at no charge.
CDL will coordinate courier or shipping services as indicated.
CDL will comply with HIPAA and protect patient information.
The practice agrees to collect and submit specimens per CDL guidelines.

This agreement outlines the mutual expectations between the provider and Clinical Diagnostic Laboratory.

5. Authorized Signature

Provider Signature:

Authorized Name:

Date:

New Client Registration Form

Clinical Diagnostic Laboratory

"Redefining Diagnostics, Advancing Care"