COVID-19 Testing Startup

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To expedite the process of rolling out 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 can be sent to our team at info@aculabs.com.

Facility Info
Staff Info
Unit Info
Courier Info

FACILITY CONTACT INFORMATION

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

MD NPI #

Customer Service Rep

Administrator Information

Administrator's Name (required)

Administrator's Email (required)

Director of Nursing Information

Director of Nursing's Name (required)

Director of Nursing's Email (required)

Business Office Information

Business Office Contact - Name (required)

Business Office Contact - Title (required)

Business Office Contact - Phone (required)

Business Office Contact - Email (required)

IT Department Information

IT Department Contact - Name (required)

IT Department Contact - Title (required)

IT Department Contact - Phone (required)

IT Department Contact - Email (required)

FACILITY UNIT INFORMATION

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)

SPECIMEN COLLECTION INFORMATION

Aculabs Specimen Box Location: (required)

Special Pick-Up Instructions:

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