Facility Set-Up Form Type of testing*Check all that apply. Molecular Blood Toxicology Type of Account* Drug screening in office? Yes No Client Name* Client Site(s) Client Site Name Actions Edit Delete There are no Client Sites. Add Client Site Maximum number of client sites reached. Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Fax Key ContactKey Contact Name* Title* Email* Direct Line* Physician/Provider Name & NPI *(required)Name AddRemove LIMS UsersFirst/Last Name Email Address AddRemoveBilling ContactName* Phone* Email Additional InfoNotesShipping* Courier Route FedEx Pick Up Do you need a dropbox?* Yes or no4 Hr. Window For Pick Up:* (Example: 9:00am - 1:00pm)Latest Time For Pick Up:* (Example: 11:00am)Sales Rep* Please contact facilities@ildp.com with any questions.EmailThis field is for validation purposes and should be left unchanged. Get in Touch 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. Health Care Provider Patient Name* Practice Name* Email* Phone*Provider Name Subject* Message*Preferred Mode of Contact* Email Phone Please do not submit any Personal Health Information (PHI).Consent* By clicking submit, you agree to the terms of ILDP's Privacy Policy. EmailThis field is for validation purposes and should be left unchanged.