Genova Diagnostics
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Client Application


To ensure the quickest turnaround time, be sure to include an electronic copy of the ordering Healthcare Practitioner's license that shows the expiration date or a copy of a voided prescription pad form showing license number.

* Indicates Required Information

General Information

Practitioner Details

Applicable to US practitioners only

License

To ensure the quickest possible turnaround time in setting up your account, we ask that you provide an electronic copy of the Ordering Healthcare Practitioner's license that shows the expiration date or a copy of a voided prescription pad form.

Practitioners licensed outside of the US should check with their country's health ministry or regulatory body regarding appropriate documentation.

Shipping Address

Collection packs and results will be sent to this address

Billing Information

Billing Contact Information

Please take a moment to review the following options and let us know which one applies to your account:
Billing Statement Preference

If you are wanting to combine your account with another practitioner/entity for reasons other than billing, please submit your application and then proceed to get in touch with your new account rep by completing this form: https://www.gdx.net/contact/more-information

Billing Address

Billing Method Preferences

These preferences may need to be adjusted by our account set-up specialist team based on regulatory requirements for your state.

Convenient and Secure Automated Payment Options for Practitioner Billing

At the beginning of each month, Genova Diagnositcs will provide a comprehensive list of charges made to your card. Automated payments will be charged at the end of each month for any balances remaining on the account.

Please provide your card details and specify your preference for storing and using it for balances billed to your professional account.

I authorize Genova Diagnostics to charge my card:

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