New Customer Setup
Clinical Laboratory Qualifications
DIRECT CUSTOMERS
575 N. Patterson Ave., Winston Salem, NC 27101
336-722-8910 •Fax 336-722-8915
www.carolinachemistries.com
New Direct Customer
Account/Customer Name:
Facility Legal Name (if different):
Facility Official State of Registration:
Bill to Address:
Ship to Address:
Street Address
Street Address
City
City
State
State
Postal Code
Postal Code
DIVISION (select one)
01 Hospital Lab (<400 beds)
02 Hospital Lab (>400 beds)
03 Dr. Office/Clinic/Medical Group Lab
04 Private Lab
07 International Lab
08 Government
09 International Distributor
10 Veterinary Lab
11 Lab Chain/Reference Lab
12 Teaching Establishment
13 Lease Companies
14 Research/Development/Manufacturers
17 Service Organization
18 Consultant
CONTACTS
ACCOUNTS PAYABLE
LAB MANAGER
PURCHASING
LAB DIRECTOR
Name
Phone Number
Fax Number
Email Address
Facility has space requirements for a dedicated Clinical Laboratory?
Yes
No
Laboratory has qualified personnel that meets the CLIA requirements for the type of testing performed?
Yes
No
Status of CLIA License:
Complete
In Progress
Not Filed
Enter CLIA#, In Progress Explanation, or Not Filed Explanation:
Certificate of Compliance
Certificate of Accreditation
Customer acknowledges CLC marketed chemistry analyzers are not CLIA Waived (POC) products, and are intended for use in a clinical laboratory.
By selecting the "Submit" button, you are signing this Agreement electronically. Customer signature below acknowledges that the information contained above is true and accurate.
Customer Signature:
Title:
Date: