Healthcare Providers
Get Started

The form below is intended for healthcare providers who wish to sign up for access to our provider portal, where you can begin ordering our genetic test. Please fill out the information below to complete your registration.

Not Ready to Order Yet?

If you have questions about Genomind's services or would like to contact us for more information, please visit our Contact & Support page.

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Contact Information

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Record Type ID*

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Case Owner*

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I am a..*

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Subject*

First Name*

Last Name*

Preferred Name

Let us know how you'd prefer to be addressed (e.g., Dr. Mike or Mr. Smith).

Email*

Business Phone*

Business Phone Extension

Fax

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Perfect! How can we help you today?*

I would like to..

Practice Information

What country do you practice in?*

Practice or Company Name*

(Note: this will become your future account name)

Address*

Street Address Address Line 2

City*

State*

Zip Code*

What EMR do you use?

What is your area of interest?

Professional Information

Credentials:*

You must have verifiable credentials to order Genomind testing.

Your NPI (National Provider Identifier)*

If you are not a prescribing healthcare provider, you are not eligible to utilize Genomind's services.

Specialty*

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Other Specialty:

Do you provide Telehealth services?*

Yes

Which location do you serve via Teleheath?

Additional Information

Event Code (if applicable)

How did you hear about us?

Would you like to share anything else?

Comments

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Get Started – Healthcare Provider

Healthcare Providers Get Started

Contact Information

Practice Information

Professional Information

Additional Information

Healthcare Providers
Get Started