Contact Us

First Name*

Last Name*

Email*

Phone*

Company/Clinic Name*

Region*
—Please choose an option—United StatesAustraliaOther

Are you a/an?*
—Please choose an option—An EnterpriseA Healthcare ProviderA Consumer/PatientAn InvestorA Partner

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What segment best represents your enterprise?*
—Please choose an option—Employee Wellbeing/Wellness VendorsWorksite Health CentersEmployer Healthcare CoalitionsEBC/BrokerNutraceutical/Supplement IndustrySelf-Insured EmployersPayor ASOsOther

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Type of provider*
—Please choose an option—Functional/Integrative MedicineConcierge MedicineOB/GYNPrimary CareImaging CenterSurgeryGenetic CounselorOncologyAcademic Medical Center/High Risk Women’s Health CenterAcademic Precision Medicine Program

What do you want to do?*
—Please choose an option—I want to set up a geneType provider accountI want follow upOther

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Address*

City*

State*

Zip/Post Code*

Fax Number

Main Office Contact Name* (This person will be the designated account holder for your geneType physician portal where you order tests and receive results)

Main Office Contact Email*

Ordering Licensed Provider Name* (GeneType can only be ordered by a healthcare provider)

NPI#*

Ordering Licensed Provider Email* (If the provider wants to be notified of report delivery, we need their email)

What type of office implementation process are you interested in?*
I have a cash-pay practice and I am interested in wholesale pricing options to incorporate into my offeringI don’t want to deal with billing and I am interested in geneType billing my patient directly (self pay)

How do you want to offer geneType, through telehealth or in office visits?*
Interested in having geneType drop shipping to my patient once I submit the orderInterested in having kits in office on consignment to use during consultations

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I’d prefer to be contacted by:
—Please choose an option—PhoneEmail

I’d prefer to be contacted during:
—Please choose an option—MorningAfternoonEvening

I’d like to talk to:
—Please choose an option—SalesMedical AffairsOrdering Assistance/Lab QuestionsTechnical HelpBilling

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What do you want to do?*
I want to order a test through a telehealth providerI want more information to talk to my doctorQuestions about billingOther

Preferred Clinic* (If you don’t have a clinic, please write "N/A")

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Comments

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