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PHYSICIAN CONTACT FORM

Note: All fields marked in BOLD are required.

NAME:

FACILITY/PRACTICE:

E-MAIL:

PHONE:

ADDRESS:

CITY:
STATE:
ZIP:

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.

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