New Client Registration - Washington University Pathology Services

Practice Name *

Office Manager First Name

Last Name

Phone *

Email *

Fax

Practice Website Address

Address *

Address

Line 1

Line 2

City

State/Province

Zip

Country

Physician First Name

Physician Last Name

Phone

NPI Number

Medicare participation *

Physician participates in Medicare

Physician opted out of Medicare

Physician needs Medicare opt-out form

Practice Hours

Specimen Pickup

I will call as needed to schedule specimen pickups

I would like specimens picked up at schedule times

Specimen Pickup Schedule

Pick up my specimens at the scheduled times on these days of the week. We schedule pickups Monday-Saturday.

Ordering

Paper requisitions

Electronic medical records (EMR)

Select your preferred ordering method(s). Check all that apply.

Report Delivery

Electronic Medical Records (EMR)

Fax

Post mail

Courier

Select your preferred report delivery method(s). Check all that apply.

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