Doctors Registration

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Testaro Labs doctors registration form. This form is only intended for doctors to register as a Testaro Labs service provider.

SURNAME(Required)

FIRST NAME(Required)

PRACTICE NAME(Required)

PRACTICE NUMBER(Required)

CELL NUMBER

PHONE NUMBER

EMAIL ADDRESS FOR RESULTS(Required)

SALES CONTACT NAME

PHYSICAL ADDRESS

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

DO YOU WANT ACCESS TO THE DOCTOR'S PHONE APPLICATION?

YES

FIRST NAME

CONTACT NUMBER

EMAIL FOR RESULTS

RECEPTIONIST EMAIL FOR RESULTS (if necessary)

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