Practitioner Registration

 

First Name *

Last Name *

Title

Gender

Preferred Delivery Method of test results *

How did you hear about us

Email *

Spectify

Phone 1 *

Phone 2

Username *

Password *
Password is at least 8 characters including one uppercase letter and number

Confirm Password*
Password does not match

Fax

Address 1 *

Address 2

City *

State *

Zip *

Website

Preferred method of payment

Country *

Account Contract

Clinic Name *

Doctor Name *

Billing Address *

Billing Address

Billing Address

Billing Address

Phone *

Fax

Email *

The purpose of this communication is to ensure that your office and PCI agree on the account terms as outlined below:

1. Your office will be billed the first week of each month for any patient specimens received with your office designated as � referring practitioner � that does not include payment.
2. Accounts payable/net 30. Or you may chooseto enroll in auto pay in which case we will charge your credit card at the end of each billing cycle. You will receive an emailed receipt when charged.Please check box below if you choose this option. By enrolling in auto-pay you will receive a 10% discount on all of our tests.
3. Full payment is required for each billing statement unless other arrangements have been made.
4. Delinquent accounts may be charged interest at 18% per annum from date of service.
5. In the event that an account is sent to collections, your office will be held responsible for all collection costs.

Enroll in Auto Pay :

We do not accept American express credit cards.

Credit Card *

Exp*

CVC *

We are pleased to work with you and will always strive to provide the best and most prompt service to you and your patients. By printing your name and title below you are accepting the terms of this agreement.

Office representative name *

Title*