Doctors Registration

Doctors Registration Form

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

SURNAME

FIRST NAME

PRACTICE NAME

PRACTICE NUMBER

CELL NUMBER

PHONE NUMBER

EMAIL ADDRESS FOR RESULTS

SALES CONTACT NAME

FULL PHYSICAL ADDRESS

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

Yes No

FIRST NAME

CONTACT NUMBER

EMAIL FOR RESULTS

RECEPTIONIST EMAIL FOR RESULTS (if necessary)