Fill out the Client Information and Physician Authorization Form below. A copy will be automatically sent to Qitek Labs.

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Client Information and Physician Authorization Form

  • Account Information

  • Testing Services and Estimated Monthly Volume

  • Payer Mix

  • Reporting Preferences (Preferred Method)

  • Shipping Information

  • Electronic Order Entry Authorization

    I hereby authorize the individual listed below to electronically access Qitek Lab's web portal and order tests at my discretion. I further authorize the individual identified below as "Site Administrator" to add and edit user access for our practice/facility.

  • Physician Signature Record

    Please include all physician ordering tests. The individuals listed below are authorized to sign patient test requisitions (limited to MD, DO, DC, PA, or ARNP only). RN's are not authorized to sign test requisitions. The person(s) below understand and acknowledge that they will only order tests that they believe to be medically necessary to ensure patient compliance with the therapy that they have prescribed.
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY

  • Sales Information

    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
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