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www.mayocliniclabs.com Open in urlscan Pro
23.36.238.219  Public Scan

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URL: https://www.mayocliniclabs.com/customer-service/mayoaccess/lwNewUser.html?env=mmlaccess.com
Submission: On March 10 via manual from US — Scanned from DE

Form analysis 3 forms found in the DOM

Name: catalog_search — GET /test-catalog/search

<form id="catalog-search" action="/test-catalog/search" method="get" name="catalog_search" class="catalog_search_widget">
  <div class="search-box" id="search_form_">
    <input type="text" class="search-text search_form_text ui-autocomplete-input" name="q" placeholder="Search Test Name" aria-label="Search the Test Catalog" autocomplete="off" id="search_">
    <button class="btn bd-search-docs-toggle search_form_go" type="submit">
      <span class="icon icon-search"></span>
    </button>
    <div class="suggestion-block">
      <ul id="ui-id-1" tabindex="0" class="ui-menu ui-widget ui-widget-content ui-autocomplete ui-front" unselectable="on" style="display: none;"></ul>
    </div>
  </div>
  <div class="alphabet-wrapper">
    <ul>
      <li><a href="/test-catalog/alphabetical/A">A</a></li>
      <li><a href="/test-catalog/alphabetical/B">B</a></li>
      <li><a href="/test-catalog/alphabetical/C">C</a></li>
      <li><a href="/test-catalog/alphabetical/D">D</a></li>
      <li><a href="/test-catalog/alphabetical/E">E</a></li>
      <li><a href="/test-catalog/alphabetical/F">F</a></li>
      <li><a href="/test-catalog/alphabetical/G">G</a></li>
      <li><a href="/test-catalog/alphabetical/H">H</a></li>
      <li><a href="/test-catalog/alphabetical/I">I</a></li>
      <li><a href="/test-catalog/alphabetical/J">J</a></li>
      <li><a href="/test-catalog/alphabetical/K">K</a></li>
      <li><a href="/test-catalog/alphabetical/L">L</a></li>
      <li><a href="/test-catalog/alphabetical/M">M</a></li>
      <li><a href="/test-catalog/alphabetical/N">N</a></li>
      <li><a href="/test-catalog/alphabetical/O">O</a></li>
      <li><a href="/test-catalog/alphabetical/P">P</a></li>
      <li><a href="/test-catalog/alphabetical/Q">Q</a></li>
      <li><a href="/test-catalog/alphabetical/R">R</a></li>
      <li><a href="/test-catalog/alphabetical/S">S</a></li>
      <li><a href="/test-catalog/alphabetical/T">T</a></li>
      <li><a href="/test-catalog/alphabetical/U">U</a></li>
      <li><a href="/test-catalog/alphabetical/V">V</a></li>
      <li><a href="/test-catalog/alphabetical/W">W</a></li>
      <li><a href="/test-catalog/alphabetical/X">X</a></li>
      <li><a href="/test-catalog/alphabetical/Y">Y</a></li>
      <li><a href="/test-catalog/alphabetical/Z">Z</a></li>
      <li><a href="/test-catalog/alphabetical/NUM">#</a></li>
    </ul>
  </div>
</form>

Name: gs — GET /search

<form name="gs" id="nav_site_search" method="get" action="/search">
  <div class="search-box">
    <input type="text" name="q" maxlength="256" class="search-input site-search-text search_input ui-autocomplete-input" id="search-input" title="Search Mayo Clinic Laboratories" placeholder="Site Search" aria-label="Search Mayo Clinic Laboratories"
      autocomplete="off">
    <button class="btn btn-search" type="submit" id="nav_search_btn">
      <span class="icon icon-search"></span> Search </button>
    <button class="btn btn-cancel" type="button">Cancel</button>
    <div class="site-suggestion-block">
      <ul id="ui-id-2" tabindex="0" class="ui-menu ui-widget ui-widget-content ui-autocomplete ui-front" unselectable="on" style="display: none;"></ul>
    </div>
  </div>
</form>

POST lwNewUserProcess.php

<form id="MainFrom" action="lwNewUserProcess.php" method="post" enctype="multipart/form-data">
  <input type="hidden" name="env" value="mmlaccess.com">
  <h4>You do not have access to data associated with the laboratory. Submit a request for access.</h4>
  <p>Verify or complete the following information. Fields marked with an asterisk (<span class="required_marker text-danger text-danger">*</span>) are required.</p>
  <input name="subject" class="d-none" size="1">
  <div class="form-heading my-3">
    <h4>Medical Facility</h4>
  </div>
  <div class="form-group mt-2">
    <label for="facility_name"><span class="required_marker text-danger">*</span> Company Name <a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the name of the medical facility to be associated with the account.<br>
                Example: XYZ Hospital <i>or</i> Jane Doe Clinic</span></a></label>
    <input id="facility_name" type="text" size="30" value="" name="facility[name]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_specialty">Medical Specialty</label>
    <input id="facility_specialty" type="text" size="30" value="" name="facility[specialty]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_primary_referring_location"><span class="required_marker text-danger">*</span> Primary Referring Location</label>
    <input id="facility_primary_referring_location" type="text" size="30" value="" name="facility[primary_referring_location]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_address"><span class="required_marker text-danger">*</span> Address<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the street address of the medical facility. Use up to two lines.<br>
                Example: <br>
                123 Main St <i>or</i> 1010 CLEAR STREET<br>
                PO Box 123</span></a> </label>
    <input id="facility_address" type="text" size="30" value="" name="facility[address]" class="form-control">
    <input id="facility_address_2" type="text" size="30" value="" name="facility[address_2]" class="form-control mt-2">
  </div>
  <div class="form-group">
    <label for="facility_city"><span class="required_marker text-danger">*</span> City<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the city or town name of the medical facility.<br>
                Example: Anytown <i>or</i> OTTAWA</span></a></label>
    <input id="facility_city" type="text" size="30" value="" name="facility[city]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_state"><span class="required_marker text-danger">*</span> State/Province <a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the state or other principal subdivision (such as Province or County) of the medical facility.<br>
                Example: PA <i>or</i> ON</span></a> </label>
    <input id="facility_state" type="text" size="30" value="" name="facility[state]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_postal_code"><span class="required_marker text-danger">*</span> Postal Code<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the postal code of the medical facility. <br>
                Example: 15200 <i>or</i> K1A 0B1</span></a> </label>
    <input id="facility_postal_code" type="text" size="30" value="" name="facility[postal_code]" class="form-control">
  </div>
  <div class="form-group">
    <label for=""><span class="required_marker text-danger">*</span> Country <a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Select the country of the medical facility.<br>
                Example: United States <i>or</i> Canada</span></a> </label>
    <select name="facility[country]" class="form-control">
      <option value="">- Select one -</option>
      <option value="United States ">United States </option>
      <option value="Canada">Canada</option>
      <option value="Afghanistan">Afghanistan</option>
      <option value="Aland Islands">Aland Islands</option>
      <option value="Albania">Albania</option>
      <option value="Algeria">Algeria</option>
      <option value="American Samoa">American Samoa</option>
      <option value="Andorra">Andorra</option>
      <option value="Angola">Angola</option>
      <option value="Anguilla">Anguilla</option>
      <option value="Antarctica">Antarctica</option>
      <option value="Antigua and Barbuda">Antigua and Barbuda</option>
      <option value="Argentina">Argentina</option>
      <option value="Armenia">Armenia</option>
      <option value="Aruba">Aruba</option>
      <option value="Australia">Australia</option>
      <option value="Austria">Austria</option>
      <option value="Azerbaijan">Azerbaijan</option>
      <option value="Bahamas">Bahamas</option>
      <option value="Bahrain">Bahrain</option>
      <option value="Bangladesh">Bangladesh</option>
      <option value="Barbados">Barbados</option>
      <option value="Belarus">Belarus</option>
      <option value="Belgium">Belgium</option>
      <option value="Belize">Belize</option>
      <option value="Benin">Benin</option>
      <option value="Bermuda">Bermuda</option>
      <option value="Bhutan">Bhutan</option>
      <option value="Bolivia">Bolivia</option>
      <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
      <option value="Botswana">Botswana</option>
      <option value="Bouvet Island">Bouvet Island</option>
      <option value="Brazil">Brazil</option>
      <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
      <option value="Brunei Darussalam">Brunei Darussalam</option>
      <option value="Bulgaria">Bulgaria</option>
      <option value="Burkina Faso">Burkina Faso</option>
      <option value="Burundi">Burundi</option>
      <option value="Cambodia">Cambodia</option>
      <option value="Cameroon">Cameroon</option>
      <option value="Canada">Canada</option>
      <option value="Cape Verde">Cape Verde</option>
      <option value="Cayman Islands">Cayman Islands</option>
      <option value="Central African Republic">Central African Republic</option>
      <option value="Chad">Chad</option>
      <option value="Chile">Chile</option>
      <option value="China">China</option>
      <option value="Christmas Island">Christmas Island</option>
      <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
      <option value="Colombia">Colombia</option>
      <option value="Comoros">Comoros</option>
      <option value="Congo">Congo</option>
      <option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
      <option value="Cook Islands">Cook Islands</option>
      <option value="Costa Rica">Costa Rica</option>
      <option value="Cote D'Ivoire">Cote D'Ivoire</option>
      <option value="Croatia">Croatia</option>
      <option value="Cuba">Cuba</option>
      <option value="Cyprus">Cyprus</option>
      <option value="Czech Republic">Czech Republic</option>
      <option value="Denmark">Denmark</option>
      <option value="Djibouti">Djibouti</option>
      <option value="Dominica">Dominica</option>
      <option value="Dominican Republic">Dominican Republic</option>
      <option value="East Timor">East Timor</option>
      <option value="Ecuador">Ecuador</option>
      <option value="Egypt">Egypt</option>
      <option value="El Salvador">El Salvador</option>
      <option value="Equatorial Guinea">Equatorial Guinea</option>
      <option value="Eritrea">Eritrea</option>
      <option value="Estonia">Estonia</option>
      <option value="Ethiopia">Ethiopia</option>
      <option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
      <option value="Faroe Islands">Faroe Islands</option>
      <option value="Fiji">Fiji</option>
      <option value="Finland">Finland</option>
      <option value="France">France</option>
      <option value="French Guiana">French Guiana</option>
      <option value="French Polynesia">French Polynesia</option>
      <option value="French Southern Territories">French Southern Territories</option>
      <option value="Gabon">Gabon</option>
      <option value="Gambia">Gambia</option>
      <option value="Georgia">Georgia</option>
      <option value="Germany">Germany</option>
      <option value="Ghana">Ghana</option>
      <option value="Gibraltar">Gibraltar</option>
      <option value="Greece">Greece</option>
      <option value="Greenland">Greenland</option>
      <option value="Grenada">Grenada</option>
      <option value="Guadeloupe">Guadeloupe</option>
      <option value="Guam">Guam</option>
      <option value="Guatemala">Guatemala</option>
      <option value="Guernsey">Guernsey</option>
      <option value="Guinea">Guinea</option>
      <option value="Guinea-Bissau">Guinea-Bissau</option>
      <option value="Guyana">Guyana</option>
      <option value="Haiti">Haiti</option>
      <option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>
      <option value="Honduras">Honduras</option>
      <option value="Hong Kong">Hong Kong</option>
      <option value="Hungary">Hungary</option>
      <option value="Iceland">Iceland</option>
      <option value="India">India</option>
      <option value="Indonesia">Indonesia</option>
      <option value="Iraq">Iraq</option>
      <option value="Ireland">Ireland</option>
      <option value="Isle of Man">Isle of Man</option>
      <option value="Israel">Israel</option>
      <option value="Italy">Italy</option>
      <option value="Jamaica">Jamaica</option>
      <option value="Japan">Japan</option>
      <option value="Jersey">Jersey</option>
      <option value="Jordan">Jordan</option>
      <option value="Kazakhstan">Kazakhstan</option>
      <option value="Kenya">Kenya</option>
      <option value="Kiribati">Kiribati</option>
      <option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
      <option value="Korea, Republic of">Korea, Republic of</option>
      <option value="Kosovo">Kosovo</option>
      <option value="Kuwait">Kuwait</option>
      <option value="Kyrgyzstan">Kyrgyzstan</option>
      <option value="Laos">Laos</option>
      <option value="Latvia">Latvia</option>
      <option value="Lebanon">Lebanon</option>
      <option value="Lesotho">Lesotho</option>
      <option value="Liberia">Liberia</option>
      <option value="Libya">Libya</option>
      <option value="Liechtenstein">Liechtenstein</option>
      <option value="Lithuania">Lithuania</option>
      <option value="Luxembourg">Luxembourg</option>
      <option value="Macao">Macao</option>
      <option value="Macedonia">Macedonia</option>
      <option value="Madagascar">Madagascar</option>
      <option value="Malawi">Malawi</option>
      <option value="Malaysia">Malaysia</option>
      <option value="Maldives">Maldives</option>
      <option value="Mali">Mali</option>
      <option value="Malta">Malta</option>
      <option value="Marshall Islands">Marshall Islands</option>
      <option value="Martinique">Martinique</option>
      <option value="Mauritania">Mauritania</option>
      <option value="Mauritius">Mauritius</option>
      <option value="Mayotte">Mayotte</option>
      <option value="Mexico">Mexico</option>
      <option value="Micronesia">Micronesia</option>
      <option value="Moldova">Moldova</option>
      <option value="Monaco">Monaco</option>
      <option value="Mongolia">Mongolia</option>
      <option value="Montenegro">Montenegro</option>
      <option value="Montserrat">Montserrat</option>
      <option value="Morocco">Morocco</option>
      <option value="Mozambique">Mozambique</option>
      <option value="Myanmar">Myanmar</option>
      <option value="Namibia">Namibia</option>
      <option value="Nauru">Nauru</option>
      <option value="Nepal">Nepal</option>
      <option value="Netherlands">Netherlands</option>
      <option value="Netherlands Antilles">Netherlands Antilles</option>
      <option value="New Caledonia">New Caledonia</option>
      <option value="New Zealand">New Zealand</option>
      <option value="Nicaragua">Nicaragua</option>
      <option value="Niger">Niger</option>
      <option value="Nigeria">Nigeria</option>
      <option value="Niue">Niue</option>
      <option value="Norfolk Island">Norfolk Island</option>
      <option value="Northern Mariana Islands">Northern Mariana Islands</option>
      <option value="Norway">Norway</option>
      <option value="Oman">Oman</option>
      <option value="Pakistan">Pakistan</option>
      <option value="Palau">Palau</option>
      <option value="Palestine">Palestine</option>
      <option value="Panama">Panama</option>
      <option value="Papua New Guinea">Papua New Guinea</option>
      <option value="Paraguay">Paraguay</option>
      <option value="Peru">Peru</option>
      <option value="Philippines">Philippines</option>
      <option value="Pitcairn">Pitcairn</option>
      <option value="Poland">Poland</option>
      <option value="Portugal">Portugal</option>
      <option value="Puerto Rico">Puerto Rico</option>
      <option value="Qatar">Qatar</option>
      <option value="Romania">Romania</option>
      <option value="Russian Federation">Russian Federation</option>
      <option value="Rwanda">Rwanda</option>
      <option value="Saint Helena">Saint Helena</option>
      <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
      <option value="Saint Lucia">Saint Lucia</option>
      <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
      <option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
      <option value="Samoa">Samoa</option>
      <option value="San Marino">San Marino</option>
      <option value="Sao Tome and Principe">Sao Tome and Principe</option>
      <option value="Saudi Arabia">Saudi Arabia</option>
      <option value="Senegal">Senegal</option>
      <option value="Serbia">Serbia</option>
      <option value="Seychelles">Seychelles</option>
      <option value="Sierra Leone">Sierra Leone</option>
      <option value="Singapore">Singapore</option>
      <option value="Slovakia">Slovakia</option>
      <option value="Slovenia">Slovenia</option>
      <option value="Solomon Islands">Solomon Islands</option>
      <option value="Somalia">Somalia</option>
      <option value="South Africa">South Africa</option>
      <option value="Spain">Spain</option>
      <option value="Sri Lanka">Sri Lanka</option>
      <option value="Sudan">Sudan</option>
      <option value="Suriname">Suriname</option>
      <option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
      <option value="Swaziland">Swaziland</option>
      <option value="Sweden">Sweden</option>
      <option value="Switzerland">Switzerland</option>
      <option value="Syrian Arab Republic">Syrian Arab Republic</option>
      <option value="Taiwan">Taiwan</option>
      <option value="Tajikistan">Tajikistan</option>
      <option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
      <option value="Thailand">Thailand</option>
      <option value="Timor-Leste">Timor-Leste</option>
      <option value="Togo">Togo</option>
      <option value="Tokelau">Tokelau</option>
      <option value="Tonga">Tonga</option>
      <option value="Trinidad and Tobago">Trinidad and Tobago</option>
      <option value="Tunisia">Tunisia</option>
      <option value="Turkey">Turkey</option>
      <option value="Turkmenistan">Turkmenistan</option>
      <option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
      <option value="Tuvalu">Tuvalu</option>
      <option value="Uganda">Uganda</option>
      <option value="Ukraine">Ukraine</option>
      <option value="United Arab Emirates">United Arab Emirates</option>
      <option value="United Kingdom">United Kingdom</option>
      <option value="United States">United States</option>
      <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
      <option value="Uruguay">Uruguay</option>
      <option value="Uzbekistan">Uzbekistan</option>
      <option value="Vanuatu">Vanuatu</option>
      <option value="Venezuela">Venezuela</option>
      <option value="Vietnam">Vietnam</option>
      <option value="Virgin Islands, British">Virgin Islands, British</option>
      <option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
      <option value="Wallis and Futuna">Wallis and Futuna</option>
      <option value="Western Sahara">Western Sahara</option>
      <option value="Yemen">Yemen</option>
      <option value="Yugoslavia">Yugoslavia</option>
      <option value="Zambia">Zambia</option>
      <option value="Zimbabwe">Zimbabwe</option>
    </select>
  </div>
  <div class="form-group">
    <label for="facility_phone"><span class="required_marker text-danger">*</span> Phone Number<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the medical facility's phone number with area code or international dialing code.<br>
                Example: 555-555-0123 <i>or</i> 011 354 56789</span></a> </label>
    <input id="facility_phone" type="tel" size="30" value="" name="facility[phone]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_secondary_phone">Secondary Phone Number</label>
    <input id="facility_secondary_phone" type="tel" size="30" value="" name="facility[secondary_phone]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_fax">Fax Number<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the medical facility's fax number with area code or international dialing code.<br>
                Example: 555-555-0123 <i>or</i> 011 354 56789</span></a> </label>
    <input id="facility_fax" type="tel" size="30" value="" name="facility[fax]" class="form-control">
  </div>
  <div class="form-heading my-3">
    <h4>Referring Laboratory Information</h4>
  </div>
  <div class="form-group mt-2">
    <label for="facility_referring_laboratory_name"><span class="required_marker text-danger">*</span> Referring Laboratory Name</label>
    <input id="facility_referring_laboratory_name" type="text" size="30" value="" name="facility[referring_laboratory_name]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_referring_laboratory_phone"><span class="required_marker text-danger">*</span> Phone Number</label>
    <input id="facility_referring_laboratory_phone" type="tel" size="30" value="" name="facility[referring_laboratory_phone]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_referring_laboratory_address"><span class="required_marker text-danger">*</span> Address<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the street address of the referring laboratory facility. Use up to two lines.<br>
                Example: <br>
                123 Main St <i>or</i> 1010 CLEAR STREET<br>
                PO Box 123</span></a> </label>
    <input id="facility_referring_laboratory_address" type="text" size="30" value="" name="facility[referring_laboratory_address]" class="form-control">
    <input id="facility_referring_laboratory_address_2" type="text" size="30" value="" name="facility[referring_laboratory_address_2]" class="form-control mt-2">
  </div>
  <div class="form-group">
    <label for="facility_referring_laboratory_city"><span class="required_marker text-danger">*</span> City<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the city or town name of the medical facility.<br>
                Example: Anytown <i>or</i> OTTAWA</span></a> </label>
    <input id="facility_referring_laboratory_city" type="text" size="30" value="" name="facility[referring_laboratory_city]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_referring_laboratory_state"><span class="required_marker text-danger">*</span> State/Province<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the state or other principal subdivision (such as Province or County) of the medical facility.<br>
                Example: PA <i>or</i> ON</span></a> </label>
    <input id="facility_referring_laboratory_state" type="text" size="30" value="" name="facility[referring_laboratory_state]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_referring_laboratory_postal_code"><span class="required_marker text-danger">*</span> Postal Code<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Type the postal code of the medical facility. <br>
                Example: 15200 <i>or</i> K1A 0B1</span></a> </label>
    <input id="facility_referring_laboratory_postal_code" type="text" size="30" value="" name="facility[referring_laboratory_postal_code]" class="form-control">
  </div>
  <div class="form-group">
    <label for=""><span class="required_marker text-danger">*</span> Country<a class="tooltip" tabindex="-1" href="javascript:void(0)"><img src="/images/icons/new-info-icon.png" alt=""><span>Select the country of the medical facility.<br>
                Example: United States <i>or</i> Canada</span></a> </label>
    <select name="facility[referring_laboratory_country]" class="form-control">
      <option value="">- Select one -</option>
      <option value="United States ">United States </option>
      <option value="Canada">Canada</option>
      <option value="Afghanistan">Afghanistan</option>
      <option value="Aland Islands">Aland Islands</option>
      <option value="Albania">Albania</option>
      <option value="Algeria">Algeria</option>
      <option value="American Samoa">American Samoa</option>
      <option value="Andorra">Andorra</option>
      <option value="Angola">Angola</option>
      <option value="Anguilla">Anguilla</option>
      <option value="Antarctica">Antarctica</option>
      <option value="Antigua and Barbuda">Antigua and Barbuda</option>
      <option value="Argentina">Argentina</option>
      <option value="Armenia">Armenia</option>
      <option value="Aruba">Aruba</option>
      <option value="Australia">Australia</option>
      <option value="Austria">Austria</option>
      <option value="Azerbaijan">Azerbaijan</option>
      <option value="Bahamas">Bahamas</option>
      <option value="Bahrain">Bahrain</option>
      <option value="Bangladesh">Bangladesh</option>
      <option value="Barbados">Barbados</option>
      <option value="Belarus">Belarus</option>
      <option value="Belgium">Belgium</option>
      <option value="Belize">Belize</option>
      <option value="Benin">Benin</option>
      <option value="Bermuda">Bermuda</option>
      <option value="Bhutan">Bhutan</option>
      <option value="Bolivia">Bolivia</option>
      <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
      <option value="Botswana">Botswana</option>
      <option value="Bouvet Island">Bouvet Island</option>
      <option value="Brazil">Brazil</option>
      <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
      <option value="Brunei Darussalam">Brunei Darussalam</option>
      <option value="Bulgaria">Bulgaria</option>
      <option value="Burkina Faso">Burkina Faso</option>
      <option value="Burundi">Burundi</option>
      <option value="Cambodia">Cambodia</option>
      <option value="Cameroon">Cameroon</option>
      <option value="Canada">Canada</option>
      <option value="Cape Verde">Cape Verde</option>
      <option value="Cayman Islands">Cayman Islands</option>
      <option value="Central African Republic">Central African Republic</option>
      <option value="Chad">Chad</option>
      <option value="Chile">Chile</option>
      <option value="China">China</option>
      <option value="Christmas Island">Christmas Island</option>
      <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
      <option value="Colombia">Colombia</option>
      <option value="Comoros">Comoros</option>
      <option value="Congo">Congo</option>
      <option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
      <option value="Cook Islands">Cook Islands</option>
      <option value="Costa Rica">Costa Rica</option>
      <option value="Cote D'Ivoire">Cote D'Ivoire</option>
      <option value="Croatia">Croatia</option>
      <option value="Cuba">Cuba</option>
      <option value="Cyprus">Cyprus</option>
      <option value="Czech Republic">Czech Republic</option>
      <option value="Denmark">Denmark</option>
      <option value="Djibouti">Djibouti</option>
      <option value="Dominica">Dominica</option>
      <option value="Dominican Republic">Dominican Republic</option>
      <option value="East Timor">East Timor</option>
      <option value="Ecuador">Ecuador</option>
      <option value="Egypt">Egypt</option>
      <option value="El Salvador">El Salvador</option>
      <option value="Equatorial Guinea">Equatorial Guinea</option>
      <option value="Eritrea">Eritrea</option>
      <option value="Estonia">Estonia</option>
      <option value="Ethiopia">Ethiopia</option>
      <option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
      <option value="Faroe Islands">Faroe Islands</option>
      <option value="Fiji">Fiji</option>
      <option value="Finland">Finland</option>
      <option value="France">France</option>
      <option value="French Guiana">French Guiana</option>
      <option value="French Polynesia">French Polynesia</option>
      <option value="French Southern Territories">French Southern Territories</option>
      <option value="Gabon">Gabon</option>
      <option value="Gambia">Gambia</option>
      <option value="Georgia">Georgia</option>
      <option value="Germany">Germany</option>
      <option value="Ghana">Ghana</option>
      <option value="Gibraltar">Gibraltar</option>
      <option value="Greece">Greece</option>
      <option value="Greenland">Greenland</option>
      <option value="Grenada">Grenada</option>
      <option value="Guadeloupe">Guadeloupe</option>
      <option value="Guam">Guam</option>
      <option value="Guatemala">Guatemala</option>
      <option value="Guernsey">Guernsey</option>
      <option value="Guinea">Guinea</option>
      <option value="Guinea-Bissau">Guinea-Bissau</option>
      <option value="Guyana">Guyana</option>
      <option value="Haiti">Haiti</option>
      <option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>
      <option value="Honduras">Honduras</option>
      <option value="Hong Kong">Hong Kong</option>
      <option value="Hungary">Hungary</option>
      <option value="Iceland">Iceland</option>
      <option value="India">India</option>
      <option value="Indonesia">Indonesia</option>
      <option value="Iraq">Iraq</option>
      <option value="Ireland">Ireland</option>
      <option value="Isle of Man">Isle of Man</option>
      <option value="Israel">Israel</option>
      <option value="Italy">Italy</option>
      <option value="Jamaica">Jamaica</option>
      <option value="Japan">Japan</option>
      <option value="Jersey">Jersey</option>
      <option value="Jordan">Jordan</option>
      <option value="Kazakhstan">Kazakhstan</option>
      <option value="Kenya">Kenya</option>
      <option value="Kiribati">Kiribati</option>
      <option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
      <option value="Korea, Republic of">Korea, Republic of</option>
      <option value="Kosovo">Kosovo</option>
      <option value="Kuwait">Kuwait</option>
      <option value="Kyrgyzstan">Kyrgyzstan</option>
      <option value="Laos">Laos</option>
      <option value="Latvia">Latvia</option>
      <option value="Lebanon">Lebanon</option>
      <option value="Lesotho">Lesotho</option>
      <option value="Liberia">Liberia</option>
      <option value="Libya">Libya</option>
      <option value="Liechtenstein">Liechtenstein</option>
      <option value="Lithuania">Lithuania</option>
      <option value="Luxembourg">Luxembourg</option>
      <option value="Macao">Macao</option>
      <option value="Macedonia">Macedonia</option>
      <option value="Madagascar">Madagascar</option>
      <option value="Malawi">Malawi</option>
      <option value="Malaysia">Malaysia</option>
      <option value="Maldives">Maldives</option>
      <option value="Mali">Mali</option>
      <option value="Malta">Malta</option>
      <option value="Marshall Islands">Marshall Islands</option>
      <option value="Martinique">Martinique</option>
      <option value="Mauritania">Mauritania</option>
      <option value="Mauritius">Mauritius</option>
      <option value="Mayotte">Mayotte</option>
      <option value="Mexico">Mexico</option>
      <option value="Micronesia">Micronesia</option>
      <option value="Moldova">Moldova</option>
      <option value="Monaco">Monaco</option>
      <option value="Mongolia">Mongolia</option>
      <option value="Montenegro">Montenegro</option>
      <option value="Montserrat">Montserrat</option>
      <option value="Morocco">Morocco</option>
      <option value="Mozambique">Mozambique</option>
      <option value="Myanmar">Myanmar</option>
      <option value="Namibia">Namibia</option>
      <option value="Nauru">Nauru</option>
      <option value="Nepal">Nepal</option>
      <option value="Netherlands">Netherlands</option>
      <option value="Netherlands Antilles">Netherlands Antilles</option>
      <option value="New Caledonia">New Caledonia</option>
      <option value="New Zealand">New Zealand</option>
      <option value="Nicaragua">Nicaragua</option>
      <option value="Niger">Niger</option>
      <option value="Nigeria">Nigeria</option>
      <option value="Niue">Niue</option>
      <option value="Norfolk Island">Norfolk Island</option>
      <option value="Northern Mariana Islands">Northern Mariana Islands</option>
      <option value="Norway">Norway</option>
      <option value="Oman">Oman</option>
      <option value="Pakistan">Pakistan</option>
      <option value="Palau">Palau</option>
      <option value="Palestine">Palestine</option>
      <option value="Panama">Panama</option>
      <option value="Papua New Guinea">Papua New Guinea</option>
      <option value="Paraguay">Paraguay</option>
      <option value="Peru">Peru</option>
      <option value="Philippines">Philippines</option>
      <option value="Pitcairn">Pitcairn</option>
      <option value="Poland">Poland</option>
      <option value="Portugal">Portugal</option>
      <option value="Puerto Rico">Puerto Rico</option>
      <option value="Qatar">Qatar</option>
      <option value="Romania">Romania</option>
      <option value="Russian Federation">Russian Federation</option>
      <option value="Rwanda">Rwanda</option>
      <option value="Saint Helena">Saint Helena</option>
      <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
      <option value="Saint Lucia">Saint Lucia</option>
      <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
      <option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
      <option value="Samoa">Samoa</option>
      <option value="San Marino">San Marino</option>
      <option value="Sao Tome and Principe">Sao Tome and Principe</option>
      <option value="Saudi Arabia">Saudi Arabia</option>
      <option value="Senegal">Senegal</option>
      <option value="Serbia">Serbia</option>
      <option value="Seychelles">Seychelles</option>
      <option value="Sierra Leone">Sierra Leone</option>
      <option value="Singapore">Singapore</option>
      <option value="Slovakia">Slovakia</option>
      <option value="Slovenia">Slovenia</option>
      <option value="Solomon Islands">Solomon Islands</option>
      <option value="Somalia">Somalia</option>
      <option value="South Africa">South Africa</option>
      <option value="Spain">Spain</option>
      <option value="Sri Lanka">Sri Lanka</option>
      <option value="Sudan">Sudan</option>
      <option value="Suriname">Suriname</option>
      <option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
      <option value="Swaziland">Swaziland</option>
      <option value="Sweden">Sweden</option>
      <option value="Switzerland">Switzerland</option>
      <option value="Syrian Arab Republic">Syrian Arab Republic</option>
      <option value="Taiwan">Taiwan</option>
      <option value="Tajikistan">Tajikistan</option>
      <option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
      <option value="Thailand">Thailand</option>
      <option value="Timor-Leste">Timor-Leste</option>
      <option value="Togo">Togo</option>
      <option value="Tokelau">Tokelau</option>
      <option value="Tonga">Tonga</option>
      <option value="Trinidad and Tobago">Trinidad and Tobago</option>
      <option value="Tunisia">Tunisia</option>
      <option value="Turkey">Turkey</option>
      <option value="Turkmenistan">Turkmenistan</option>
      <option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
      <option value="Tuvalu">Tuvalu</option>
      <option value="Uganda">Uganda</option>
      <option value="Ukraine">Ukraine</option>
      <option value="United Arab Emirates">United Arab Emirates</option>
      <option value="United Kingdom">United Kingdom</option>
      <option value="United States">United States</option>
      <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
      <option value="Uruguay">Uruguay</option>
      <option value="Uzbekistan">Uzbekistan</option>
      <option value="Vanuatu">Vanuatu</option>
      <option value="Venezuela">Venezuela</option>
      <option value="Vietnam">Vietnam</option>
      <option value="Virgin Islands, British">Virgin Islands, British</option>
      <option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
      <option value="Wallis and Futuna">Wallis and Futuna</option>
      <option value="Western Sahara">Western Sahara</option>
      <option value="Yemen">Yemen</option>
      <option value="Yugoslavia">Yugoslavia</option>
      <option value="Zambia">Zambia</option>
      <option value="Zimbabwe">Zimbabwe</option>
    </select>
  </div>
  <div class="form-heading my-3">
    <h4>User Information</h4>
  </div>
  <div class="form-group mt-2">
    <label for="facility_user_title">Title</label>
    <input id="facility_user_title" type="text" size="30" value="" name="facility[user_title]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_user_first_name"><span class="required_marker text-danger">*</span> First Name</label>
    <input id="facility_user_first_name" type="text" size="30" value="" name="facility[user_first_name]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_user_middle_name">Middle Name</label>
    <input id="facility_user_middle_name" type="text" size="30" value="" name="facility[user_middle_name]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_user_last_name"><span class="required_marker text-danger">*</span> Last Name</label>
    <input id="facility_user_last_name" type="text" size="30" value="" name="facility[user_last_name]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_user_suffix">Suffix</label>
    <input id="facility_user_suffix" type="text" size="30" value="" name="facility[user_suffix]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_user_degree">Degree</label>
    <input id="facility_user_degree" type="text" size="30" value="" name="facility[user_degree]" class="form-control">
  </div>
  <div class="form-group">
    <label for="facility_user_upin_npi">UPIN/NPI</label>
    <input id="facility_user_upin_npi" type="text" size="30" value="" name="facility[user_upin_npi]" class="form-control">
  </div>
  <div class="form-heading my-3">
    <h4>Login Information</h4>
  </div>
  <div class="form-group space-top">
    <label for="login_email"><span class="required_marker text-danger">*</span> Email Address</label>
    <input id="login_email" type="email" size="30" value="" name="facility[login_email]" class="form-control">
  </div>
  <div class="form-group">
    <label for="login_email_confirm"><span class="required_marker text-danger">*</span> Confirm Email</label>
    <input id="login_email_confirm" type="email" size="30" value="" name="facility[login_email_confirm]" class="form-control">
  </div>
  <div class="mt-5 mb-5 form-group text-center">
    <input class="btn btn-primary" type="submit" name="submit" value="Submit Request">
  </div>
</form>

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* AddressType the street address of the medical facility. Use up to two lines.
Example:
123 Main St or 1010 CLEAR STREET
PO Box 123
* CityType the city or town name of the medical facility.
Example: Anytown or OTTAWA
* State/Province Type the state or other principal subdivision (such as Province
or County) of the medical facility.
Example: PA or ON
* Postal CodeType the postal code of the medical facility.
Example: 15200 or K1A 0B1
* Country Select the country of the medical facility.
Example: United States or Canada - Select one - United States
CanadaAfghanistanAland IslandsAlbaniaAlgeriaAmerican
SamoaAndorraAngolaAnguillaAntarcticaAntigua and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia
and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei
DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman
IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling)
IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta
RicaCote D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican
RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial
GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and Mcdonald IslandsHondurasHong
KongHungaryIcelandIndiaIndonesiaIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic
People's Republic ofKorea, Republic
ofKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands
AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern
Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New
GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint
LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao
Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra
LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri
LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab
RepublicTaiwanTajikistanTanzania, United Republic
ofThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited
Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying
IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin
Islands, U.S.Wallis and FutunaWestern SaharaYemenYugoslaviaZambiaZimbabwe
* Phone NumberType the medical facility's phone number with area code or
international dialing code.
Example: 555-555-0123 or 011 354 56789
Secondary Phone Number
Fax NumberType the medical facility's fax number with area code or international
dialing code.
Example: 555-555-0123 or 011 354 56789

REFERRING LABORATORY INFORMATION

* Referring Laboratory Name
* Phone Number
* AddressType the street address of the referring laboratory facility. Use up to
two lines.
Example:
123 Main St or 1010 CLEAR STREET
PO Box 123
* CityType the city or town name of the medical facility.
Example: Anytown or OTTAWA
* State/ProvinceType the state or other principal subdivision (such as Province
or County) of the medical facility.
Example: PA or ON
* Postal CodeType the postal code of the medical facility.
Example: 15200 or K1A 0B1
* CountrySelect the country of the medical facility.
Example: United States or Canada - Select one - United States
CanadaAfghanistanAland IslandsAlbaniaAlgeriaAmerican
SamoaAndorraAngolaAnguillaAntarcticaAntigua and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia
and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei
DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman
IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling)
IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta
RicaCote D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican
RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial
GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and Mcdonald IslandsHondurasHong
KongHungaryIcelandIndiaIndonesiaIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic
People's Republic ofKorea, Republic
ofKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands
AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern
Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New
GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint
LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao
Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra
LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri
LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab
RepublicTaiwanTajikistanTanzania, United Republic
ofThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited
Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying
IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin
Islands, U.S.Wallis and FutunaWestern SaharaYemenYugoslaviaZambiaZimbabwe

USER INFORMATION

Title
* First Name
Middle Name
* Last Name
Suffix
Degree
UPIN/NPI

LOGIN INFORMATION

* Email Address
* Confirm Email


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