MEDICAL PRACTICE REGISTRATION FORM

PRACTICE INFORMATION

reports will be mailed to the primary address, unless otherwise specified

PRACTICE NAME:
SPECIALTY:
PHONE:
FAX:
PRIMARY ADDRESS:
PRIMARY EMAIL:
CITY:
STATE:
ZIP CODE:

BILLING METHOD

reports will be mailed to the primary address, unless otherwise specified

  •  Client Bill Patient Bill Insurance Bill

INTERESTED IN THE FOLLOWING REPORT(S):

Liquid Biopsy:

 CancerIntercept™ Detect
 CancerIntercept™ Monitor
 CancerIntercept™ Monitor + Clinical Trial Matching

Health and Wellness:

 SkinFit™
 PathwayFit®
 Healthy Woman DNA Insight®
 Healthy Weight DNA Insight®

Pharmacogenomics:

 Mental Health DNA Insight®
 Pain Medication DNA Insight®

Hereditary Cancer Panels:

 BRCATrue®
 BreastTrue™ High Risk Panel®
 ColoTrue®

Cardiac:

 Cardiac DNA Insight®

Carrier Screening:

 Carrier Status DNA Insight®

REPORT DELIVERY METHOD

  •  Pathway Atrium™ (electronic report)

Authorized Atrium™ Administrator (email required)

LAST NAME:
FIRST NAME:
TITLE:
EMAIL:
PHONE:
FAX:

ORDERING PHYSICIAN(S) INFORMATION

LAST NAME:
FIRST:
MI:
NPI #:
SPECIALTY:
STATES LICENSED IN (eg., CA, WA):
EMAIL:
Draw your signature with  your mouse.

LAST NAME:
FIRST:
MI:
NPI #:
SPECIALTY:
STATES LICENSED IN (eg., CA, WA):
EMAIL:
Draw your signature with  your mouse.

LAST NAME:
FIRST:
MI:
NPI #:
SPECIALTY:
STATES LICENSED IN (eg., CA, WA):
EMAIL:
Draw your signature with  your mouse.

To register additional physicians, complete and attach an additional Medical Practice Registration Form (note: complete only the “Ordering Physician(s) Information” section).

DATE:
PATHWAY GENOMICS SALES REPRESENTATIVE:

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