Client Registration Form

Client Registration

To become a new client of Patients Choice Laboratories, simply fill out the form below. Once submitted, a member of our team will reach out within 24 hours. We are excited about working with you and your patients!
Your Name*

First NameLast Name
Your Email*
A confirmation will be sent to this email.
Facility Name*
This name will be on all reports.
Location Name
If multiple locations within same practice.
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Facility Phone Number*
Facility Fax Number*
Facility Contact*

First NameLast Name
Facility Contact E-mail*
24-Hour Emergency Phone Number (for critical levels)*
Please provide us a 24-hour emergency phone number for us to call in the event of any critical levels. This number needs to be monitored and answered 24-hours a day. If you have multiple numbers for this, please provide them below.
24-Hour Emergency Secondary Phone Number (for critical levels)
24-Hour Emergency Monitored Email (for critical levels)
example@example.com
Patients Choice Sales Rep

First NameLast Name
Add to Sales Rep COPIA Account?

YesNo
Sales Rep COPIA Username
If you don't have one, put your name and one will be created for you.
Report Delivery Preference*

COPIA InboxFaxOther (specify)
Have email notifications sent when results are available in COPIA?

YesNo
Number of Additional COPIA Users:
All ordering providers and the facility contact are assigned a COPIA username and password by default. If additional usernames are needed, please select "COPIA Inbox" and complete form info.
COPIA User Info
COPIA User Info
COPIA User Info
Report Delivery Fax
ALL reports for this clinic will be faxed to this number.

Request Arkstone antimicrobial stewardship and treatment recommendation reports with your results.*

Yes, please includeNo, these reports are not needed
How many providers are at this location?
Provider 1 Info
Provider 2 Info
Provider 3 Info
Provider 4 Info
Provider 5 Info
Provider 6 Info
Provider 7 Info
Provider 8 Info
Provider 9 Info
Provider 10 Info
All orders require providers full name and NPI. If orders do not come with this information, this could cause a delay in the release of reports until all necessary information is receieved.

Shipping Preference*

UPSFedExOther (specify)
Pickup Schedule*

On-Call / Drop-BoxDaily Monday through FridayDay Specific
On-call pickups can be scheduled by calling in to the lab when the pickup is needed. Depending on the area of the clinic, UPS and FedEx require a 2-hour window and need to know before noon local time.
These forms must be filled out to setup routine pickups with UPS or FedEx. Please click the link to open the form in a new tab and compete after finishing this client registration.

UPS Pickup Request Form

FedEx Pickup Request
Additional Information
Any information that we might need that was not included on this form.
Should be Empty: