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Contact and Email Notification Update

The information you provide will be used to update our LIS system and facilitate our emailed Client Letter/Lab Update. The form will take only a few moments to submit. In appreciation of your time, we will be making a $5,000.00 donation to the American Cancer Society if we can achieve a 75% response rate. Your response will help make that contribution possible. Thank you for your continued support as our partner in serving your clients and patients.

Current Client Number   Telephone Number (Regular Hours)
Client Name   Preferred Contact for Calls
Client Address Line 1   Fax Number
Client Address Line 2   Telephone Number (After Hours)
Client Address Line 3   Other Account Numbers
City      
State      
Zip      
         
Sendout Referral Supervisor Name
  Lab Manager/Lab Director Supervisor Name
Sendout Referral Supervisor Email   Lab Manager/Lab Director Supervisor Email
Send Lab Update to Referral Supervisor?   Send Lab Update to Lab Manager/Director?
Send Turnaround Report to Referral Supervisor?   Send Turnaround Report to Lab Manager/Director?
Send Utilization Report to Referral Supervisor?   Send Utilization Report to Lab Manager/Director?
         
IT Contact Name   Medical Director/Pathologist Name
IT Contact Email   Medical Director/Pathologist Email
Send Lab Update to IT Contact?   Send Lab Update to Medical Director/Pathologist?
Send Turnaround Report to IT Contact?   Send Turnaround Report to Medical Director/Pathologist?
Send Utilization Report to IT Contact?   Send Utilization Report to Medical Director/Pathologist?
         
       







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For test information, please call Client Services at 800-421-4449.

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