"*" indicates required fields Client Name* Address* Address City State Zip Code Phone*Fax Provider* NPI# Additional Providers on page 2 Office Manager* E-Mail Address* Lab Contact E-Mail Address IT Contact E-Mail Address Care Evolve Access Y N Label Paper Y N EMR / PM EMR /PM VersionDirection Uni Directional Bi Directional Bridge Y N Results Partials Finals Label Printer Y N Results Printer Y N Automatic Patient Email Y N Pickup times:Monday Hours : Minutes AM PM AM/PM Tuesday Hours : Minutes AM PM AM/PM Wednesday Hours : Minutes AM PM AM/PM Thursday Hours : Minutes AM PM AM/PM Friday Hours : Minutes AM PM AM/PM Saturday Hours : Minutes AM PM AM/PM Sunday Hours : Minutes AM PM AM/PM Box Location Daily Y N Will Call Y N Timed Stop Y N Key Required Y N Sales Representative Provider NPI# Provider NPI# Provider NPI# Provider NPI# Provider NPI# Provider NPI# Provider NPI# Provider NPI#
