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:

EMAIL:

PHONE:

FAX:

MOBILE:

ADDRESS:

CITY:

STATE:

ZIP CODE:

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:

ACCOUNT NAME & NUMBER LISTED WITH EMR:

SUPPLIES NEEDED:

Mark amount needed:

Requisitions

20ml Formalin Vials

Bags

Lock Box (Floor)

DIF Kits

FedEx Airbills

Ship Kits

Other

TERRITORY ACCOUNT MANAGER:

COMMENTS: