Join Our Provider Network Form

Please complete all required fields. Upon submission, a dedicated Sales Associate will reach out to your Point of Contact to help set up your account.

Practitioner Details

First Name*

Last Name*

Email*

Mobile*

Provider Credentials*

NPI Number

Practice Name*

Practice Size*

Speciality*

How did you learn about SpectraCell Laboratories?*

What is your time frame for establishing an account?*

Any experience using functional lab testing within your practice?*

Which functional lab testing platforms or services have you used?

Do you currently have patients waiting to be tested?*

I would like to be contacted about the New Provider Promotion

Buy 3 Micronutrient Tests and receive 1 Telomere Test or MTHFR Test at no cost. Promotion eligibility and redemption details will be reviewed by a SpectraCell representative after account setup. View promotion terms and eligibility.

Which SpectraCell test(s) are you most interested in offering to your patients?

Office Address

Address*

City*

State/Province*

Zip Code*

Country*

Point of Contact

A dedicated Sales Associate will contact you directly to help set up your account. Please provide the best direct phone number and email for the appropriate point of contact.

Contact Name/Title*

Contact Email*

Contact Phone Number*

Preferred Contact Method*

Yes, I have read the Terms and Conditions and permit SpectraCell to contact me for my account setup.*

Thank you for taking the time to fill your details! Our team at SpectraCell will go through all the details and reach out to you in 3-5 working days.

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