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COVID-19 (Coronavirus) Testing Partner Set-Up Form for Gravity Diagnostics
Your First Name
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Your Last Name
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Your Email Address
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Name of Facility
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Facility Address:
Address 1
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Address 2
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City
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State
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Zip Code
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Provider Listed On ALL Orders:
Provider Last Name
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Provider First Name
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NPI
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Provider Last Name
Provider First Name
Office Contact Phone Number
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Office Contact Email
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How To Receive Results (You Can Do Both)
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Fax
In Gravity's Portal
Fax Number for Results
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Portal Contact First Name
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Portal Contact Last Name
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Portal Contact Email
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Order initial kits (Swab and biohazard bag) amount to be mailed to the address above. *Please order a week's worth of supplies.
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60
120
180
240
300
More than 300
You selected more than 300. Please explain why you need this many kits.
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