New Account Set-Up Form

Practitioner Information

Will this account be for personal/family use or for resell to clients/patients?*

About Your Practice

Would you like ELISA/ACT Biotechnologies to Refer Patients to You?*
Would you like to receive emails from our company about testing, news & information, etc.?*
Services Provided*
Payment: ELISA/ACT does NOT bill to insurance. EAB will provide a receipt upon request. Full payment is due with sample. Please select how you would like to handle payment*

Please contact Client Services at (800) 553-5472 to put credit card information and billing address on file.

How did you hear about us?*
What kind of testing are you interested in?*

By clicking "Submit", you will be entered into our email mailing list. We will not share your information with anyone.