Client Registration

*Please complete the following form so that we will be able to provide services for your office.*
Name of Office:
Mailing address of office for receipt of pathology reports:
Mailing address for receipt of specimen supplies if different than above:
Office telephone number(s):	/
Office fax number(s):	/
Email Address for Receipt of Digital Microscopic Images or Correspondence to the Physician:
Physician's name as you prefer it to appear on our reports:
Physician's UPIN #:
Primary Specialty:
Name of Office Manager:
Office Manager's telephone number:
Annual Number of specimens anticipated to be referred to our laboratory:
Additional Comments:
We look forward to providing services for your office.