Account Enrollment – Vikor Scientific

Please indicate the person placing an order*

Sales Representative
Customer

Is this account a lead acquired from an Email Campaign In-Practice Visit request?*

Yes
No

Would you like to...*

Enroll Only
Enroll and Create New Supply Order

Is this account a lead acquired from a society meeting?*

No
Yes

Society Meeting

Would you like to...*

Activate Account

Account Information

Facility Name*

This field is hidden when viewing the form

Date Activated*

Implementation Date*

CMS ID / Clinic NPI*

Corporate Affiliation

EMR Vendor*

EMR Vendor Name*

If unsure, indicate as UNKNOWN.

Address*

Street Address Suite City State ZIP Code

Phone*

Fax*

Office Contact

Email*

Missing Info Contact(s) to Add*

1
2
3

Missing Info Contact Name*

Missing Info Contact Email*

Missing Info Contact 2 Name*

Missing Info Contact 2 Email*

Missing Info Contact 3 Name*

Missing Info Contact 3 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

Portal Login User Setup

Click "+" to add additional users.

Email	Weekend Phone

Physician Specialty*

Is this Urgent Care open 7 days a week?*

Yes
No

Do you want margins reported on Dysplastic Nevi?

Yes
No

Do you want margins reported on malignancies?

Yes
No

Do you want Mild, Moderate, or Severe grading on Dysplastic Neve?

Yes
No

Do you want Melanomas reported verbally to you?

Yes
No

Is it okay to verbally report Melanomas to staff?

Yes
No

Do you want second opinions on Melanomas, Sarcomas, and Lymphomas?

Yes
No

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

Shipping Details for Supplies

Ship to

Ship to Account
Ship to Sales Representative
Ship to Another Address

Ship to Address*

Street Address Suite City State / Province / Region ZIP / Postal Code

Sales Representative's Address*

Street Address Suite City State / Province / Region ZIP / Postal Code

ATTN*

Account Address*

Street Address Suite City State ZIP Code

Is this a trunk stock account?*

Yes
No

Select Lab (Kits & Labels)*

Vikor Scientific
KorPath

Provider Information

Providers*

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

Name (First Last)	Title	NPI

Provider Signature Attestation(s)

Drop files here or

Accepted file types: pdf, Max. file size: 25 MB.

Supplies

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

Kits

All kits include a requisition and the requested collection device unless a special request is made in the NOTES section.

Respira-ID™ (Nasopharyngeal)

Urine-ID™ (Urine Swab)

Urine-ID™ (Urine Swab AND Specimen Cup)

Toilet Hats (must be ordered separately from Urine kits)

Gastro-ID™ (General Swab)

Derm-ID™ (General Swab)

Derm-ID™ (TISSUE Kit)

Wound-ID™ (General Swab)

Wound-ID™ (TISSUE Kit)

Nail-Fungal ID (Swab)

Nail-Fungal ID (Tissue)

Surgical-ID (Swab)

Surgical-ID (Tissue)

Vaginal-ID™ (General Swab)

STI-ID™ (General Swab)

Pharmacogenetics (Buccal Swab)

Joint-ID™

EMA Workaround Labels

Urine/Vaginal Workaround Labels

Shipping Supplies

All shipping supplies are limited to 25 per order.

# of FedEx Labels

Please enter a number less than or equal to 25.

# of UPS Clinical Labels

Please enter a number less than or equal to 25.

# of Shipping Bags

Please enter a number less than or equal to 25.

Type of Shipping Bags*

* To set up a pickup, regardless of label type, please visit our Pickup Request page

Is this the first supply order for the account?*

Yes
No

Person Placing Order*

Email for Order Updates*

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Notes