VHL COVID-19 Provider Inquiry

COVID-19 Provider Inquiry

If you would like to offer our COVID-19 and/or Respiratory Pathogen Panel tests to your patients, please complete the form below, and a Vibra Health Lab representative will contact you shortly with more information.
Practice Name *
Contact Person *

First Name Last Name
Contact Number *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Specialty: *

Hospital Assisted Living Facility Skilled Nursing Facility Primary Care Home Health Urgent Care
Do you practice telemedicine?

Yes No No, but would like to
Where will patient samples be collected?

Your office A Vibra Health Lab collection site
Anticipated weekly sample volume
Helps us with logistics and supply orders
Questions or Comments:
Should be Empty:

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