Become a ZRT Provider
  1. ZRT Laboratory is pleased to offer accounts to qualified healthcare providers. Complete this form to establish an account with us.

    If you are not licensed to order laboratory testing, please email us or call 866.600.1636.

    = Required field

  2. Contact Information

  3. Ordering Health Care Provider's Name*
    Please enter Ordering Health Care Professional Name.
  4. Credential(s)*
    Please enter your Professional Designation.
  5. License #
    Please enter your License #.
  6. NPI#
    The NPI# field must be only numbers.
  7. Business Name
    (If diff. than Ordering Provider, e.g. "Wellness Clinic")
  8. Phone*
    Only numbers are allowed in this field.
    (Numbers only)
  9. Country*
    Country is required.
  10. Country Name*
    Invalid Input
  11. Physical/Street Address*
    Street Address is required.
  12. City*
    City is required.
  13. State*
    State is required.
  14. Postal Code*
    Postal Code is required.
  15. Physical/Shipping Address*
    Invalid Input
  16. Other Information

  17. Test results are available through the myZRT secure web portal. Please provide an e-mail address for login instructions. A confirmation will be sent to this email.
  18. Email*
    An Email Address is required.
  19. How would you like to be contacted for follow-up?
  20. Practice Specialty:
    Invalid Input
  21. Comments or Questions?
    Invalid Input
  22. Please tell us where you heard about us:*
    Please fill in where you heard about us.
  23. Please specify:
    Invalid Input
  24. Billing

  25. Billing Selection*
    Billing Option is a required selection.
  26. Billing Selection*
    Billing Selection is required.
  27. Billing Contact Info*
    A/P Contact is required with your Billing Selection.
    (Include Name, Phone, Email)
  28. Billing Fax
    Only numbers are allowed in this field.
    (Numbers only)
  29. Billing Country*
    Country is required.
  30. Billing Address*
    Billing Address is required.
  31. Country Name*
    Invalid Input
  32. Autocharge Form must be sent separately as a physical signature is required. Account setup will not be completed until this signed form is received.
  33. Billing Address
    Invalid Input
  34. Billing City*
    City is required.
  35. Billing State*
    State is required.
  36. Billing Postal Code*
    Postal Code is required.
  37. Billing Address*
    Invalid Input
  38. Signature

  39. Ordering Provider Agreement: By typing my FULL name below, I indicate that all information is correct. Also, I acknowledge that only licensed healthcare professionals may order laboratory testing for others, and it is my responsibility to abide by any local, state or federal laws that regulate ordering tests for others.
  40. Ordering Health Provider eSignature*
    Signature of Ordering Health Provider is Required.
  41. Prompt Pay Agreement: By typing in my FULL name below, I indicate that all information is correct. Also, I understand my specific responsibilities in the payment method chosen. If BILL PROVIDER is selected above, I agree to be financially responsible for payment of all charges associated with this account.
  42. Owner/Principal eSignature*
    Signature of Owner/Principal is Required.
    (May be same or diff. than Ordering Provider.)
  43. Please enter the characters below*
    Please enter the characters below
    Invalid Input