New Account Registration

Step 1 of 2

50%

General Info
Company/Practice Name*
Address*
Street Address Address Line 2 City State ZIP Code
Contact Person
Name*
First Last
Phone*
Email*
Payment
Subscription Plan*
Total
$0.00
Credit Card

Card Details

Cardholder Name

Form Creation
Lab Integration
Do you want to use a lab Integration*
- Yes
- No
Choose Your Lab
Lab Location Info
Lab Organization Name
Your name as it appears in the lab information system or client lab client portal if you don’t know this information reach out to your lab sales representative.
Lab Organization ID
Lab Location Name
This is the Location name as it appears in the Lab Information System, if you don't know it ask the lab sales rep, if you only have one location, this will be the same as the Organization Name
Lab Location ID
add location
- Add more locations
Lab Location Name
This is the Location name as it appears in the Lab Information System, if you don't know it ask the lab sales rep, if you only have one location, this will be the same as the Organization Name
Lab Location ID
Form Information Required
Patient Demographics*
- Yes
- No
Patient ID image upload*
- Yes
- No
Insurance card image upload*
- Yes
- No
Capture Patient signature*
- Yes
- No
Additional Fields / Forms Templates
Form Name
Form Description
Form template file
Accepted file types: jpg, gif, png, pdf.
add form
- Add more forms
Form2 Name
Form2 Description
Form2 template file
Accepted file types: jpg, gif, png, pdf.
Workflow if needed
Work flow could be something like I want the patient first to enter their demographics, then covid health screening then to sign HIPAA consent form then medical history form then
Notifications
You can receive a notification to your email once you got a new registration, Notification will be like: NEW Form Registration: Form Name: {formname}, First Name: {firstname}, Last Name: {lastname} Email: {email}, Phone: {phone} Location: {location}
Opt in for notifications
- Opt in for notifications
Email to receive notifications*