Become a DLO client

Clinic/Facility Name *

Established Clinic or New Clinic? *

If new clinic, anticipated opening date

Contact Name *

Address *

City *

State *

Zip *

Billing Address (if different from above)

Clinic/Office Phone *

After Hours Phone Number (if different from Daytime Phone Number)

Fax Number

Email *

Website

Additional Office Contact Information - Name/Phone/Email (Optional)

Specialty *

Type of practice

Overall Practice Description *

(please choose applicable type or select "other")

Office Hours *

Please list days and hours of operations

Who will billing be charged to? *

(to select multiple options, press the "Shift" key and select all options applicable)

Are you a member of a Group Purchasing Organization (GPO)? *

If you are a member of a GPO, please list their name.

Will you need a lock box? *

If your facility does not have accomodations for a lock box, please let us know in the comment section.

How often will courier service be needed? *

Where will draws be performed? *

If selecting multiple locations, please press the Shift key while making selections

Provider Name(s) and NPI Number *

Please provide all names of providers (not facility) and their 10-digit NPI number (example: First Name, Last Name, NPI Number)

Would you like to receive faxed reports/results? *

What kind of reports will be needed? *

If you want or require a client billing option with special pricing, how would you like your invoice sorted?

How did you hear about DLO? *

If you select "Sales Representative" or "Other," please indicate in the comments your Sales Representative's name or how you heard about DLO.

Comments/Questions

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