YOUR EMAIL ADDRESS:
Note: All fields marked in BOLD are required.
NAME:
FACILITY/PRACTICE:
E-MAIL:
PHONE:
ADDRESS:
What is your medical discipline?:
I currently perform testing in-house
If no, which lab(s) do you send out to?:
I currently order a Graves’ disease assay
If so, which CPT code do you use?:
How did you hear about us?:
Please send me a Thyretain informational packet. Please contact me about a Thyretain educational webinar or to schedule a Thyretain educational presentation at my office.
Comments: