Client Information Formstep 1 of 2


Please provide the following information or you may complete and return the PDF version of this form. Be sure to include an electronic copy (PDF) of the ordering Healthcare Practitioner's license that shows the expiration date or a copy of a voided prescription pad form showing license number to ensure the quickest turnaround time.

* Indicates Required Information

General Information

Practitioner Details

Individual Type 1

Office Contact

Shipping Address

Kits and results will be sent to this address

Billing Address

Please provide a billing address if it is different from your shipping address.

Online Account (myGDX)

We recommend that you make your myGDX password non-trivial, memorable, and distinct from any other that you use online. Passwords must be at least eight characters long, and may contain any combination of upper and lower case letters, numbers, spaces and/or punctuation. Remember that you are responsible for the security of your myGDX access credentials.

Miscellaneous

Billing Method Preferences

Allow the following billing methods

Prompt Pay Agreement

Genova Diagnostics, Inc. will extend the Prompt Payment Fee (Prepay) for services scheduled to the billing account specified above, provided they meet the following conditions:

Balance in full must be received by the laboratory within 30 days of the statement date.

Please select one of the following options:
  • /