Provider Application Form

Practitioner Details

Please complete all required fields and your dedicated Relationship Manager will contact you within 24 hours.

First Name*

Last Name*

Email*

Mobile*

Healthcare Provider Credentials
(MD, DC, DO, etc.)

NPI Number*
‍

Practice Name*

Practice Size*

Speciality*

How did you learn about SpectraCell Laboratories?

What is your time frame for establishing an account?*

Any experience using functional lab testing within your practice?

Do you currently have patients waiting to be tested?*

Yes I have read the Terms and Conditions and I permit SpectraCell to reach out to me

Who should your assigned Relationship Manager ask for during initial contact to set up account?

Office Contact Name/ Title*

Email*

Preferred Method of Contact*

Address*

City*

State/Province*

Zip Code*

Country*

Thank you for taking the time to fill your details! Our team at SpectraCell will go through all the details and reach out to you in 24 - 48 hours.

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