Sign Up Now — Lifetime Sciences

Ready to Begin Laboratory Ordering?

Step 1: Complete and submit all information requested below.

Step 2: A representative from Lifetime Sciences will reach out to the office contact within 2 business days to go over and collect any additional information and schedule training if needed.

Step 3: You will receive a welcome email with instructions on how to log into our portal, and information to join your scheduled training (if requested). Test kits will be mailed to the address provided.

Step 4: You are ready to begin ordering!

Facility Name

Provider Name

First Name

Last Name

Provider NPI

Office Contact

Email Address

Billing Options

Please choose one

Facility Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

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Fax Number

(###)

###

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Web Portal Users

Please list each person's name and email address that will be using the web portal.

Report Delivery

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Sales Rep

Referred By

Please Check Areas of Interest

Infectious Disease

COVID-19

Clinical

PGT

Cardio Genetics

Required

By checking this box, I affirm that I hold a valid license to order laboratory testing pursuant to Tennessee state law.

Disclaimer

By clicking submit, I hereby give authorization, to the above names users, to the Lifetime Sciences web portal. Permissions will include but are not limited to viewing and printing patient results. I acknowledge that through remote access to the web portal, my authorized users and I may obtain confidential patient information. I understand that this confidential information is protected by federal and state law, as well as the policies of Lifetime Sciences Lab. I agree my authorized users and I will comply with all applicable laws regarding the privacy and security of health information including but not limited to HIPAA.