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 Name Tax ID Phone*Fax Email* 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 VolumeToxicology Pharmacogenomics Molecular Micro (RPP/EAR/UTI/STI/Wound) Payer Mix% Medicare % Medicaid % PPO % HMO % Work Comp % Cash SignatureRepresentative* Phone*Email* SignatureDate* MM slash DD slash YYYY Δ
