Mako Medical

Account Setup Form

Provider Facility/Office Information

Provider Facility/Office Name

Please provide a name.

Address

Please provide an address.

Address 2

Phone Number

Please provide a number.

Fax Number

Please provide an email.

Critical Result Point of Contact Name

Please provide a point of contact.

Critical Result Point of Contact Phone Number

Please provide a number.

Ordering Provider Information

Ordering Provider 1 Name

Please provide a name.

Ordering Provider 1 NPI

Please provide a number.

Ordering Provider 2 Name

Ordering Provider 2 NPI

Ordering Provider 3 Name

Ordering Provider 3 NPI

Enter additional provider names and NPIs here (please separate each provider with a comma) Example: John Doe - 999999999, Juan Carlos - 999999999, Sarah Smith - 999999999, etc.

Web Portal User Information

Web Portal User 1 Full Name

Please provide a full name.

Web Portal User 1 Email

Please provide an email.

Web Portal User 2 Full Name

Web Portal User 2 Email

Web Portal User 3 Full Name

Web Portal User 3 Email

Enter additional web portal user names and emails here (please separate each user with a comma) Example: John Doe - jdoe@example.com, Juan Carlos - jcarlos@example.com, Sarah Smith - ssmith@example.com, etc.

How many COVID-19 collection kits do you need?

Please provide a number.