Facility Set-Up Form

Type of testing*
Check all that apply.
- UTI
- STI
- Respiratory
- Covid-19
- Wound
- Nail Fungus
- Toxicology
Drug screening in office?
- Yes
- No
Client*
Client Site*
Address*
Street Address Address Line 2 City State ZIP Code
Telephone
Fax
Key Contact
*This person will have access to the client portal to create orders and receive reports.
Name of Key Contact*
Email of Key Contact*
Direct Line*
Physician/Provider Name & NPI*
Name*
Notes
Date of Training
Rep Name*
Please contact info@ildp.com with any questions.
Comments
This field is for validation purposes and should be left unchanged.

If you would like to submit your request using a PDF rather than the online form, you may download the form and send it via email to info@ildp.com or fax to 1-513-860-0373.
Download Facility Set-Up PDF.

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We would love to hear from you! Whether you are a health care provider or patient, our expert team is here to answer all your questions.

Facility Set-Up Form

Key Contact

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