New Healthcare Providers Form for Maxgenlabs

Personal Information

Name*

First Name

Last Name

Business Name*

Business Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email Address*

Website*

Phone*

Please list all providers in your office who may use this test:*

International Practitioner Shipping Address - please provide all contact info below.

Where did you hear about MaxGen Labs?

if Other

License Number & Expiration Date:*

NPI Number (if applicable):

How many clients do you serve each month?

Do you have a niche?

Do you have a virtual office?*

How many genetic kits would you like?

Buccal Swab | Use the included req form to select which test you want.

How many food sensitivity kits would you like?

Dried Blood Spot | Use the included req form to select which test you want.

MaxGen Labs only opens professional accounts for licensed healthcare providers.
MaxGen Labs does not work with any insurance companies, nor will they provide coded receipts for reimbursement.
MaxGen Labs will bill the practitioner once the test sample is complete via electronic invoices sent to the email on file. MaxGen Labs does not relinquish test reports until the invoice is paid.
You may not publish any price lower than the retail price currently listed on www.maxgenlabs.com. You are free to mark up the test as high as you see fit.
MaxGen Labs reserves the right to increase fees, dissolve accounts, or make changes to these policies at any time.

Please sign below to acknowledge these policies:

Date/Time*

:

Signature*

Use your mouse or finger to draw your signature above