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BUSINESS ACCOUNT SETUP REQUEST FORM

Please fill out the form below and some will be in touch with you shortly. For urgent needs – please contact sales at 480-788-4292.

Business Type...

I am a interested in...

Setting up a Local Business Discount Account for my Employees/Members to get discounts when they are not using insurance for lab testing (No Cost to Employers) Medical Laboratory Testing General Phlebotomy Services In-Office Phlebotomy Services Mobile Phlebotomy Services Specimen Pick-Up Services COVID-19 Testing for patients/staff Other (please explain in comments section)

Contact First Name

Contact Last Name

Account Setup Contact Number

Account Setup Contact Email

Name of Business

Business Street Address

Address Line 2

City

State

Zip

Business Phone Number

Email

Fax number

Is this a secure fax number for sending patient results?

Yes No

Anticipated Weekly Testing Volume

Less than 10 10-15 15-50 50+ N/A

Healthcare Offices: Will you be doing blood draws in your office?

Yes No N/A

Questions/Requests/Additional Information (including ordering Providers if applicable):

Need Assistance?

Contact Sales: 480-788-4292 | Sales@ptchoice.com

Contact Client Services: 602-923-0605 | info@ptchoice.com

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