Fill out the Sales and Marketing Setup Form below. A copy will be automatically sent to Qitek Labs. Prefer to fill out a paper copy? Click here. Sales and Marketing Setup Form Account InformationCompany NameTax IDPhone*FaxEmail* Address*City*State*Zip Code*Contact Name*Title*Hours*Account TypeNumber of Sales Representatives*Number of Clinics Represented*Clinic Locations (States)*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% CashSignatureRepresentative*Phone*Email* SignatureDate* Date Format: MM slash DD slash YYYY
