• info@ipsumdiagnostics.com
  • 8607 Roberts Drive, Suite 125, Atlanta, GA 30350

New Account Setup - Ipsum Diagnostics

To create a new account, fill out the form below.

Practice Information
Practice Name *

Practice Address *

Address 2

City
State
ZIP

Practice Phone *

Practice Fax

Contact Person
Contact Name

Contact Phone Number

Contact Email

Provider Information
Provider First Name

Provider Middle Name

Provider Last Name

Provider NPI

Portal Instructions:

Can Reports Be Faxed to this Number?
YesNo

Report Portal?
YesNo

First Name

Last Name

Email

Are there more providers
YesNo

Other Locations
YesNo