New Client Form

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Account Demographics

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Hours of Operation:

Payer Mix % :

Logistics Information

Fedex Pick up:(days/time)
Initial Supply Order: (check all that apply)
Phlebotomist Needs: (check one)

Account Management

Clinical Director: Denise Perez
Company: Anchor Lab Services, LLC
Sales Phone: 678-619-5555 ext. 107
Sales Email: DPerez@anchorls.com

Account Preference

Report Delivery Method:*
EMR Interface Request:
Hardware Request:*
Critical/Malignancy Calls:*

Supply Request

Billing Information

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*DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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