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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
There are no Client Sites.
Maximum number of client sites reached.
Address*
Street Address City State ZIP Code
Phone
Fax
Key Contact
Key Contact Name*
Title*
Email*
Direct Line*
Physician/Provider Name & NPI *(required)
Name
LIMS Users
First/Last Name

Email Address
Billing Contact
Name*
Phone*
Email
Additional Info
Notes
Shipping*
- Courier Route
- FedEx Pick Up
Do you need a dropbox?*

Yes or no
4 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.
Email
This field is for validation purposes and should be left unchanged.

Client Site Name	Actions

There are no Client Sites.

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