Welcome to LABPORT. Please use this form to start the onboarding process, once created, you will be able to quickly and easily view participants, download reports, and generate requisition forms from one convenient portal. Once you have submitted this form, a LABPORT team member will contact the designated Portal Admin. Business Name * Address * Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Phone Number * Please enter a valid phone number. Fax Number Please enter a valid fax number. Primary Contact Name * Primary Contact Email * [email protected] Portal Admin Name * Portal Admin Email * [email protected] Please indicate the type of business Medical Facility Hospitality/Retail Corporate Office Facility Type Please indicate the type of medical facility Facility NPI Do you have more than one Medical Director. If yes, please provide primary Medical Director Yes No Medical Director Name Medical Director NPI Medical Director Email [email protected] Office Manager Contact Name Office Manager Phone Please enter a valid phone number. Office Manager Email [email protected] Do you require on-site testing events? Yes No Site Zip Code Site Contact Name Please indicate who will be on-site day of event. Site Contact Phone Number Please enter a valid phone number. Site Contact Email [email protected] How frequently will you require on-site testing? Weekly Monthly Other Please indicate the days of week you prefer for on-site testing. You can select multiple days to broaden availability. Monday Tuesday Wednesday Thursday Friday Saturday Sunday What is your preferred start time? Hour Minutes AM PM AM/PM Option How many individuals will need to be tested, on average, per event? Are you able to provide an Excel file of participant information? Yes No Are you able to text/email/provide a QR code to all participants? Yes No Name Date - Month - Day Year Date Signature Clear Submit your onboarding form Should be Empty:
