New Account Form DRAFT FORM | AccessDx Laboratory

New Account Form

Provider Information

Name

First

Last

Organization Name

Type Name Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Test Type

AccessDx Pharmacogenomics (PGx) Profile

Ordering Preference

Billing

Administrative Contact (optional)

Name

First

Last

Title

Phone

Next Steps:

AccessDx Laboratory Sales Operations will send you a Client Intake Form and Business Associate Agreement from [email protected] via AdobeSign.
Please review, sign, and submit both forms.
AccessDx Laboratory Sales Operations will send you the fully executed forms once complete.
You will be contacted by an AccessDx Laboratory team member for questions, kit requests, and portal training (if electronic ordering is selected).

By filling out this form, you agree to receive communications like newsletters, marketing or promotional materials, and other information from AccessDx Laboratory and our parent company, Aranscia. You may opt-out of receiving communications from us by using the unsubscribe link at the bottom of all emails or contacting us directly.