COVID-19 Testing Startup

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Please be aware that a pop-up will appear upon successful submission before being redirected back home.

Notice: To expedite the process for COVID-19 testing, Aculabs has set up the below form for facilities to fill out in order to make the onboarding process even easier. Further questions about using Aculabs for COVID-19 testing can be sent to info@aculabs.com.

Please ensure that all files are properly compressed and appropriately encrypted before sending.

1
Facility Info
2
Staff Info
3
Unit Info
4
Courier Info

1/4

Facility Info

Name of Facility (required)

Address Line 1 (required)

Line 2

City (required)

State (required)

Zip Code (required)

Your Name (required)

Your Email (required)

Corporation Name [or Privately Owned] (required)

Anticipated Start Date (required)

Medical Director (required)

MD NPI # (required)

Customer Rep (required)

Administrator's Name (required)

Administrator's Email (required)

Director of Nursing's Name (required)

Director of Nursing's Email (required)

Business Office Contact - Name (required)

Business Office Contact - Title (required)

Business Office Contact - Phone (required)

Business Office Contact - Email (required)

IT Department Contact - Name (required)

IT Department Contact - Title (required)

IT Department Contact - Phone (required)

IT Department Contact - Email (required)

Facility Phone Number (required)

Facility Fax Number (required)

Would you like your results faxed to this number?: (required)
YesNo

Please list your facility's units, room numbers associated with each unit, and fax number for each unit. (required)

Aculabs Specimen Box Location: (required)

Special Pick-Up Instructions:

If specimen box is located inside, does building ever lock?: (required)
YesNo