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

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(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

Email for PORTAL LOGIN*

Report Delivery will be via FAX & Online Portal

Weekend Phone

For ON CALL RESULTS

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

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

Preferred Carrier

FedEx
UPS

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.

Respira-ID™ (Nasopharyngeal)

Urine-ID™ (Urine Swab)

Urine-ID™ (Urine Swab AND Specimen Cup)

Gastro-ID™ (General Swab)

Derm-ID™ (General Swab)

Derm-ID™ (TISSUE Kit)

Wound-ID™ (General Swab)

Wound-ID™ (TISSUE Kit)

Nail-ID™ (Nail Cup)

Nail-ID™ (Nail Bag)

Vaginal-ID™ (General Swab)

Pharmacogenetics (Buccal Swab)

# of FedEx Clinical Labels

# of UPS Clinical Labels

# of RadiusFlex Labels

Is this the first supply order for the account?*

Yes
No

Person Placing Order*

Email for Order Updates*

Hidden

Notes