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?*

EAB Account Preferences

Can EAB send an LRA retest letter to patient? (Only Applicable for LRA Testing)

Results

All results are sent via secured email to the practitioner

Rotation Diet (LRA Testing Only)

A customized rotation diet can be included as part of the Patient Report (check one)*

LRA Testing Only

When questionnaire is submitted with sample, supplement recommendations should be (check one)*

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