KMI Diagnostics, Laboratory Testing Services

Account Registration Form

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Contact Information - *Denotes required fields.

Sample Type - Please check ALL that apply.

Name of Primary Clinician who will be ordering tests.*

Name of Primary Contact Person*

Phone Number* (No spaces or dashes)

Fax Number

E-mail*

Serum

Plasma

Whole Blood

Urine

Saliva

Other

Please estimate the number of samples you anticipate submitting per month. We will send you an appropriate supply of sample collection kits (always provided free-of-charge).

Billing Address (no PO Box)

Shipping Address (no PO Box)

Payment Information

Address Line 1*

Address Line 2

City*

State*

Country*

Zip+4 or Postal Code*
+

Address Line 1*

Address Line 2

City*

State*

Country*

Zip+4 or Postal Code*
+

Credit Card Type

Credit Card Number

Expiration Date

3 Digit Security Code (4 for Amex)

Alternatively, you can call us toll-free at
1-888-564-3424
to provide credit card information.

Website URL
http://www.

Any Additional Information

If you do not have a website please tell us what type of practice you have. (check all that apply)
Wellness Clinic
Anti-Aging Clinic
Women’s Health Clinic
Sports Medicine Clinic
Spa Medicine

Please enter the Anti-Spam Code number 5 into this field