Lab Account Setup Form Please compete this information to the best of your ability. If you have any questions, please give us a call at (541) 276-6032.TeamCME Member Name(Required) First Last Date(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Clinic Name(Required) Clinic Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Would you like to have your clinic information pre-printed on the drug testing forms?(Required) Yes No Do you have any additional approved contacts?(Required) Yes No Name of additional approved contact(Required)First NameLast Name Add RemoveIs your shipping information different from above?(Required) Yes No Shipping Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Due to package size, we can NOT ship to a PO BoxAll FEDERAL results and all positive, NON-FEDERAL results will be sent directly from the Medical Review Officer (MRO). Any negative NON-FEDERAL results will be sent from the lab. If you set up an WebOasis account with the lab, negative NON-FEDERAL results will be available through the WebOasis platform. (The lab will email you information about setting up WebOasis.) Billing InformationName on Credit Card(Required) First Last Credit Card Number(Required) Expiration Date(Required) CVC(Required)
