914 345 1100

New Client Form

Application Form

Please complete the application form below

Please complete the application form below, or alternatively you can download the New Client Application and fax it to 914.345.1101 or e-mail it to info@bridgedermpath.com.

    CLIENT INFORMATION: (select one)

    NEW CLIENTADD PHYSICIANADD LOCATION

    PHYSICIAN NAME:

    NPI #:

    CLINIC NAME:

    PHONE:

    FAX:

    MOBILE:

    ADDRESS:

    CITY:

    STATE:

    ZIP CODE:

    BILLING ADDRESS (if different from above)

    ADDRESS:

    CITY:

    STATE:

    ZIP CODE:

    OFFICE HOURS:

    PRIMARY CONTACT NAME/TITLE:

    LIST OTHER DOCTORS AND NPI# FROM YOUR CLINIC THAT WILL SUBMIT SPECIMENS:

    PATHOLOGY DIAGNOSTICS TESTING SERVICES DESIRED:

    List any special testing such as ENFD, DIF, Molecular, DNA Analysis, Etc

    MONTHLY VOLUME:

    WILL CLIENT SUBMIT SAMPLES DAILY?YESNO

    IF NO, MARK DAYS SAMPLES WILL BE SUBMITTED:MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY

    REPORTING OPTIONS:AUTOFAXHARD COPYWEB PORTALEMROTHER

    EMR NAME/VERSION:

    EMR VENDOR CONTACT:

    SUPPLIES NEEDED:

    Mark amount needed:

    Requisitions

    20ml Formalin Vials

    Bags

    Lock Box (Floor)

    DIF Kits

    FedEx Airbills

    Ship Kits

    Other

    TERRITORY ACCOUNT MANAGER:

    COMMENTS: