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New Client Information Form

Thank you for your interest in HEMEX Laboratories. In order for us to properly process your patient's samples, we need the following information PRIOR to any sample being received. Sample processing can be delayed if this information is NOT received before samples are sent. Additionally, HEMEX Laboratories CANNOT send out shipping kits or other supplies until this information is received.

Note to patients: This information MUST be returned to HEMEX Laboratories PRIOR TO SAMPLES BEING SHIPPED. State law REQUIRES a physician's orders for laboratory tests to be performed. Items indicated by * are required information.

*Your E-mail Address:

What Type Of Facility Is Your Office?
*Choose type
If other, please specify
*Facilty Name:
*Address:
*City:
*State:
*ZIP:
*Telephone:
  ( ) 
*FAX:
  ( ) 
   
Contact Information
Contact Name:
Contact Title/Position:
Telephone:
  ( ) 
FAX:
  ( ) 
   
Billing Information
*What type of billing will your facility be utitlizing?:
   
PATIENT RESULT REPORTING
How would you like your laboratory reports sent to you?
HEMEX will always mail a copy of the final report to your facility.
   
Physician Names and UPIN Numbers
*Provide the names and UPIN numbers of ALL physicians who will be utilizing HEMEX Laboratories for testing patient samples.
 
Physician Name 
         UPIN Number 
   
Review and Submit
Please take a moment to review your entries. If you are satisfied with all your entries, you may either print this form by using the Print Button on your browser (you may also choose Print from the File menu) or click on the "Submit Form" button below to send your information electronically. If you would like to clear the form and start over, choose the "Clear This Form" button below.

Again, thank you for your interest in HEMEX Laboratories.

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