Online Ordering Portal Signup

Are you a healthcare professional? Sign up for an online ordering account on this form for healthcare professionals.

Your Information

ROL Information

Your Full Name*

Practice Name*

Practice Type

Is this a new practice account?

If you are unsure, please select "Yes" to enter account information.

Practice Information

Customer Practice Account

Practice Name*

Address 1*

Address 2

City*

State*

Postal Code*

Phone Number*

Fax Number*

Add Provider(s) to the Account

You must submit at least one provider to link delegates. If you need to submit more than 5 new users, please email your Sales Support Specialist.

Practice Name*

Provider Information

Provider

Provider First Name*

Provider Last Name*

Provider Email Address*

NOTE: User will need access to this email address to activate their account.

Provider Email Address*

Provider Occupation*

Provider NPI Number*

Provider #2

Provider 2 First Name*

Provider 2 Last Name*

Provider 2 Email Address*

NOTE: User will need access to this email address to activate their account.

Provider 2 Email Address*

Provider 2 Occupation*

Provider 2 NPI Number*

Provider #3

Provider 3 First Name*

Provider 3 Last Name*

Provider 3 Email Address*

NOTE: User will need access to this email address to activate their account.

Provider 3 Email Address*

Provider 3 Occupation*

Provider 3 NPI Number*

Provider #4

Provider 4 First Name*

Provider 4 Last Name*

Provider 4 Email Address*

NOTE: User will need access to this email address to activate their account.

Provider 4 Email Address*

Provider 4 Occupation*

Provider 4 NPI Number*

Provider #5

Provider 5 First Name*

Provider 5 Last Name*

Provider 5 Email Address*

NOTE: User will need access to this email address to activate their account.

Provider 5 Email Address*

Provider 5 Occupation*

Provider 5 NPI Number*

Add Delegates to the Account

If you do not need to add delegates to your account, you can skip this page. If you are adding delegates, they will also be granted ordering permissions for the listed provider(s). If you need to submit more than 5 new users, please email your Sales Support Specialist.

Practice Name*

Delegate Information

Delegate #1

Delegate 1 First Name

Delegate 1 Last Name

Delegate 1 Email Address

NOTE: User will need access to this email address to activate their account.

Delegate 1 Email Address

Delegate 1 Occupation

Delegate #2

Delegate 2 First Name*

Delegate 2 Last Name*

Delegate 2 Email Address*

NOTE: User will need access to this email address to activate their account.

Delegate 2 Email Address*

Delegate 2 Occupation*

Delegate #3

Delegate 3 First Name*

Delegate 3 Last Name*

Delegate 3 Email Address*

NOTE: User will need access to this email address to activate their account.

Delegate 3 Email Address*

Delegate 3 Occupation*

Delegate #4

Delegate 4 First Name*

Delegate 4 Last Name*

Delegate 4 Email Address*

NOTE: User will need access to this email address to activate their account.

Delegate 4 Email Address*

Delegate 4 Occupation*

Delegate #5

Delegate 5 First Name*

Delegate5 Last Name*

Delegate 5 Email Address*

NOTE: User will need access to this email address to activate their account.

Delegate 5 Email Address*

Delegate 5 Occupation*

Does this account need AR-V7 Nucleus Detect collection kits?

Collection Kit Information

AR-V7 Nucleus Detect Collection Kits

Shipping Attention Name*

Shipping Address(es)

NOTE: Include shipping address(es) for all sites that need kits. Separate addresses with semi-colon.

Shipping Address(es)

Confirm Account Information

NOTES TO SALES SUPPORT

Treatment Determination

Therapy Selection

Testing And Treating

Understanding Your Diagnosis

Online Ordering Portal Signup

Quick Links

Online Ordering Portal Signup

ROL Information

Is this a new practice account?

If you are unsure, please select "Yes" to enter account information.

Customer Practice Account

Add Provider(s) to the Account

Provider Information

Provider

Provider Email Address*

Provider #2

Provider 2 Email Address*

Provider #3

Provider 3 Email Address*

Provider #4

Provider 4 Email Address*

Provider #5

Provider 5 Email Address*

Add Delegates to the Account

Delegate Information

Delegate #1

Delegate 1 Email Address

Delegate #2

Delegate 2 Email Address*

Delegate #3

Delegate 3 Email Address*

Delegate #4

Delegate 4 Email Address*

Delegate #5

Delegate 5 Email Address*

Does this account need AR-V7 Nucleus Detect collection kits?

Collection Kit Information

AR-V7 Nucleus Detect Collection Kits

Shipping Address(es)

Confirm Account Information

Quick Links

Follow Us