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: