Distributor Application | Genova Diagnostics

Company

First Name

Last Name

Phone Number

Company Website

Instagram

LinkedIn Profile

Twitter

In which country will you distribute testing?

Shipping Address, Line 1

Shipping Address, Line 2

City

State/Province/Region

Country

Postal Code

What is the highest medical degree held by a member of your staff?

Do you currently import kits and export human specimens in and out of your country?

What best describes your business model? Check all that apply.
Private Practice
Clinical Laboratory
Pharmaceutical Company
Supplement Company
Other

For diagnostic testing, which type of specimens? Check all that apply.
Stool
Blood
Urine
Saliva
N/A

What areas of testing are you interested in? Check all that apply. Gastrointestinal
Hormone
Nutritional
Food Sensitivity

Who will be promoting Genova testing? Check all that apply.
Sales Team or Rep
Marketing
Website
Doctors

How did you hear about Genova Diagnostics?

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