Account Enrollment – Vikor Scientific

Please indicate the person placing an order*

Sales Representative
Customer

Would you like to...*

Enroll Only
Enroll and Create New Supply Order

Would you like to...*

Activate Account

Is this a commercial account outside of Arizona, California, Illinois, Maryland, Michigan, Rhode Island, or Texas?*

Yes
No

Account Information

Facility Name*

Hidden

Date Activated*

Implementation Date*

Corporate Affiliation

Address*

Street Address Suite City State ZIP Code

Phone*

Fax*

Office Contact

Email

Missing Info Contact Name*

Missing Info Contact Email*

Sales Representative Name*

Sales Representative Email*

Sales Representative Cell

Sales Manager Name

Sales Manager Email

Sales Manager Cell

Accounts Payable Contact Name

Accounts Payable Contact Email

Accounts Payable Contact Phone

Name of Pharmacy Partner

Pharmacy Contact Name

Pharmacy Contact Email

Pharmacy Contact Phone

Email for PORTAL LOGIN*

Report Delivery will be via FAX & Online Portal

Weekend Phone

For ON CALL RESULTS

Please select a description of the account:*

Assisted Living Facility (NO Skilled Patients)
Nursing Home (Combination of BOTH Skilled and Non-Skilled Patients)
Nursing Home (ONLY Skilled Patients)
None of the Above

This account requires a signed facility agreement. Please reach out to your AVP to facilitate the next steps.

Shipping Details for Supplies

Ship to Account

Ship to Account
Ship to Sales Representative

ATTN*

Address*

Street Address Suite City State ZIP Code

Does Account Presently Have Daily Pick-up Service?*

Yes
No

Preferred Carrier

FedEx
UPS

Current Carrier

FedEx
UPS
Both

Do You Need Us to Schedule Daily Pickups?

Yes
No

Do you Need us to Schedule Call for Pickup Only?

Yes
No

Shipping Pickup Day/Time

Mon	Tue	Wed	Thu	Fri

Provider Information

Providers*

If PA/NP, please list name of supervising MD. Click "+" to add additional providers.

Name	Title	NPI

Supplies

For any additional items or special requests, please leave a message in the NOTES box.

Respira-ID™ (Nasopharyngeal)

Urine-ID™ (Urine Swab)

Urine-ID™ (Urine Swab AND Specimen Cup)

Gastro-ID™ (General Swab)

Wound-ID™ (General Swab)

Wound-ID™ (TISSUE Kit)

Nail-ID™ (Nail Kit)

Vaginal-ID™ (General Swab)

Pharmacogenetics (Buccal Swab)

# of FedEx Clinical Packs

# of UPS Clinical Packs

Is this the first supply order for the account?*

Yes
No

Person Placing Order*

Email for Order Updates*

Hidden

Notes