User Registration



Please enter your information below
All items with asterisks * are required


Account Information



 Check this box if patient does not have email address.
*Email (this will be used as your username)
*Password

*Legal Name

*Marital Status

*Date Of Birth

*Gender

*Sex at birth

*Phone Number

*Address


Primary Physician


*Insurance
 Check this box if you do not have insurance.
*Primary Paying Insurance
*
*
Image file types accepted: PNG, JPEG.
Secondary Insurance
Image file types accepted: PNG, JPEG.

Tertiary Insurance
Image file types accepted: PNG, JPEG.


 Check this box if you do not have a Social Security Number, Driver's License, or Government ID #
Social Security Number

Government ID

A Social Security Number or Government ID is needed in order to verify that you do not have insurance.

Why do we ask for these?






*Are you a member of a federally-recognized tribe?

*Are you eligible to receive services from the Indian Health Service, a Tribal Health Clinic, or an Urban Indian Health Program?

*Race

*Ethnicity

*Primary Language


Race, Ethnicity, Language, and Disability



The following questions are optional and your answers are confidential. We would like you to tell us your race, ethnicity, language and ability levels so that we can find and address health and service differences.

 Check this box to opt out.



Race and Ethnicity



*How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?
*Which of the following describes your racial or ethnic identity? Please check ALL that apply.





Language



*What language or languages do you use at home?
*In what language do you want us to communicate in person, on the phone, or virtually with you?
*In what language do you want us to write to you?
*Do you need or want an interpreter for us to communicate with you?
*How well do you speak English?


Disabilities



Your answers will help us find health and service differences among people with and without functional difficulties. Your answers are confidential.
*Are you deaf or do you have serious difficulty hearing?
*Are you blind or do you have serious difficulty seeing, even when wearing glasses?
*Do you have serious difficulty walking or climbing stairs?
*Because of a physical, mental or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?
*Do you have difficulty dressing or bathing?
*Do you have serious difficulty learning how to do things most people your age can learn?
*Using your usual (customary) language, do you have serious difficulty communicating?
(for example understanding or being understood by others)
*Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
*Do you have serious difficulty with the following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations?
Please enter your information below
All items with asterisks * are required


Account Information



*Email (this will be used as your username)

*Password

*Facility Name

*Practice

*Representative

*Phone

Fax

*Address

*License

*National Provider Identifier (NPI)

Notification Settings
Test Requests - Released or Rejected
Results Uploaded
Sample Issues and Troubleshooting
Sample Canceled
LabDash Feature Updates

Please enter your information below
All items with asterisks * are required


Account Information



*Email (this will be used as your username)

*Password

*Lab Name

*Representative

*Phone

Fax

*Address

*License

*Accreditation

Notification Settings
Test Requests
Issue Samples
Contact Us - Test Results
Contact Us - Start testing with LabDash
Contact Us - Request Technical Assistance
Contact Us - HIPAA, privacy, and security
Contact Us - Other
Daily Transaction Reports
LabDash Feature Updates

URL
 I have read and accept LabDash's Software Usage License
 I have read and accept LabDash's Privacy Agreement

By submitting this form I confirm that all information I provided is accurate to the best of my knowledge.

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