• 1. Account Info
  • 2. License Info
  • 3. Finance Info
  • 4. Finish
Register
Create a New Account

Establishing an account with Doctor's Data is easy, and necessary to order test kits. Once you have an account, you will also enjoy online access so you can request test kits, review results as soon as they become available, check pricing, view your account balance and more.


Get started by filling out the online account application below:
  1. Fill out practice information
  2. Upload your professional license
  3. Provide financial information and consent signatures
  4. Review information and submit
Or, you can print and complete this Account Application.

Mail the completed application and a copy of your license showing its expiration date to:

Doctor's Data, Inc.
3755 Illinois Avenue
St. Charles, IL 60174-2420
USA

Once we open your account, Doctor's Data will send a confirmation by email, along with information on signing into our site. If you have any questions about creating an account or any of our tests, please do not hesitate to contact us.


1 Primary Practitioner

Name:

Degree:    NPI:

PECOS (Medicare) status:
 Enrolled  Opted-Out  Unknown

Signature: X

2 Practice/Clinic Physical Location (Cannot be a PO Box)

Practice/Clinic Name:

Main Phone:    Extension:

Address 1:

Other Phone:    Description:

Address 2:

Fax:

City:    State/Province:

Email:

Postal Code:    Country:

Email 2:

3 Administrative Contacts

Lab Contact/Title:

Phone:    Email:

Office Contact/Title:

Phone:    Email:

Shipping Contact/Title:

Phone:    Email:

Billing Contact/Title:

Phone:    Email:

4 Courier Address for Test Kits (Cannot be a PO Box)

No PO boxes allowed.

 Same as practice/clinic physical location

Name/Attention:

Address 1:

Address 2:

City:    State/Province:

Postal Code:    Country:

5 Optional Alternate Address (PO Boxes Accepted)

Can be used for bills and other mail.

 Use practice address
 Use courier address

Name/Attention:

Address 1:

Address 2:

City:    State/Province:

Postal Code:    Country:

6 US & Canada Report Delivery Methods

All accounts have online access to results. If selected, Doctor's Data will mail hard copy reports to US & Canada clients.
 Mail hard copy reports (N/A outside US & Canada). Mail to: 
 Physical Location   Courier Address   Alternate Address
 Don't mail hard copy reports; download only. Email "results ready" notification to: 

7 Where do you want your bills sent?

Mail bills to:
 Physical Location
 Courier Address
 Alternate Address

8 How did you hear about us?

 Conference:  Email/Newsletter    Website
 Referred by:  Other:

9 Email Opt-In Address

Check here to opt-in an email address to receive promotional and informative emails. We will never sell your name to any other party and you can opt out at any time by contacting us at info@doctorsdata.com
  Email Address:

3755 Illinois Avenue
St. Charles, Il 60174-2420
800.323.2784 (US AND CANADA)
0871.218.0052 (UK)
+1.630.377.8139 (GLOBAL)
630.587.7860 (FAX)
doctorsdata.com
FOR DOCTOR'S DATA USE ONLY:
DATE RECEIVED:  
DATE ENTERED:  
ENTERED BY:  
ACCOUNT #:  
© 2018 Doctor's Data, Inc.
    All rights reserved.
    E12.18