Fill out the Client Information and Physician Authorization Form below. A copy will be automatically sent to Qitek Labs. Prefer to fill out a paper copy? Click here. Client Information and Physician Authorization Form Account InformationAccount Name*Phone*FaxEmail* Address*City*State*Zip Code*Contact Name*Title*Hours*Testing Services and Estimated Monthly VolumeToxicologyChemistryCarrier ScreeningPharmacogenomicsCancer GenomicsFamilial HypercholesterolemiaHematologyParkinson's/Alzheimer's/DementiaMolecular Micro (RPP/UTI/Wound)Payer Mix% Medicare% Medicaid% PPO% HMO% Work Comp% CashReporting Preferences (Preferred Method)Option 1 Fax to Clinic (Paper) Option 2 Web Reporting (Portal) Desired Username (8 alphanumeric characters)Desired PasswordOption 3 EMR Integration (*Special Conditions Apply) EMRContactPhoneE-mailShipping InformationPreferred Provider* UPS Daily Pick-Up Needed* Yes No Pick-Up Time Needed (HH:MM AM/PM)Location of Pick-UpElectronic Order Entry AuthorizationI 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.Name*Physician Signature RecordPlease 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.Name 1*NPI # 1*Credentials (MD/DO/DC PA/ ARNP) 1*Signature 1*Date 1* Date Format: MM slash DD slash YYYY Direct Physician E-mail 1* Name 2NPI # 2Credentials (MD/DO/DC PA/ ARNP) 2Signature 2Date 2 Date Format: MM slash DD slash YYYY Direct Physician E-mail 2 Sales InformationSales Representative*Phone*Email* Signature*Date* Date Format: MM slash DD slash YYYY Sales GroupSales Group RepresentativeSignatureDate Date Format: MM slash DD slash YYYY