Click Here To Download This Form In PDF Client Setup Form Client Number Assigned by AVANTIC Start Date: Client Location Name * Practice Name Practice / Organization Specialty Address Address Address Address City City State Alabama Alaska Arkansas Arizona 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Phone * Email * Emergency/ Internal Contact Repeater Physician A Physician NPI # Physician UPINI # Add Remove Office Hours M T W Th F S Specimen Pick Up Times M T W Th F S Main Contact Person Name Title Number Phlebotomist Name Phlebotomist Number Report Delivery Format Web Paper Fax Prelim and Finals Finals Only Report Style Requirements Requisition Requirements Panels Requested A Panels Requested B Panels Requested C Computer Requirements Special Supply Requirements Special Pricing Applicable? Yes No Provide Price List Panic Values Call All Panic Values Fax All Panic Values Custom Panic Values ACCT OF Reviewer Name Date Reviewed reCAPTCHA Submit
