New User Registration

Please enter your information below to register an account with PreventionGenetics

All testing must be ordered by a qualified healthcare provider

* - Denotes a required field.

I am a ... *

Patient/Patient's Legal Guardian
Healthcare Provider
Sendout Lab Employee
Genetic Counselor
Billing Team Member
Allied Provider or Support Staff Member

Personal Information

First Name: *

Last Name: *

Email Address: *

Position Title:

NPI#:

Contact Information

Email Address: *

Phone Number: *

Extension:

Secure Fax Number:

Institutional Information

Institution: *

Street Address *

Address 2:

City:

State / Province:

Zip Code:

Country: *

Phone Number:

Password

Password must have:

10 or more letters
At least 1 lower case letter
At least 1 upper case letter
At least 1 number
At least 1 symbol:
^ $ * . [ ] { } ( ) ? " ! @ # % & / \ , > < ' : ; | _ ~ `

Password: *

Confirm Password: *

*We respect your privacy. Please note that the information you provide on the above form will NOT be sold. This information will only be used to send you emails and notifications from PreventionGenetics.

I am requesting access to PreventionGenetics’ myPrevent electronic portal (portal). I understand that information I have access to within the portal will contain Personal Health Information (PHI). I attest that I am an employee of the covered entity listed above and I am authorized to use the PHI in order to perform my job duties. I further attest that as an employee of the covered entity listed above, I am requesting access for the purpose of ongoing treatment of patients, payment and/or healthcare operations. I will not access, disclose, or request action that violates HIPAA. I understand that PreventionGenetics reserves the right to terminate access based on restrictions or other change that adversely affects or violates HIPAA.

I affirm that the covered entity listed above allows transfer of patient results to this email domain.

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