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Activate Account

Please use the form below to enroll a new account with Vanta Diagnostics.

Account Enrollment

"*" indicates required fields

Email

This field is for validation purposes and should be left unchanged.

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CMS ID

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QuickBase Record ID

Please indicate the person placing an order*

Sales Representative

Customer

Is this account a lead acquired from an Email Campaign In-Practice Visit request?*

Yes

No

Will customer be submitting requests for testing on any Medicare Part A patients?*

Yes

No

Would you like to...*

Enroll Only

Enroll and Create New Supply Order

Is this account a lead acquired from a society meeting?*

No

Yes

Society Meeting

Is this account part of a Corporate / Multi-Site Organization?*

Yes

No

Was this account closed using the Corporate Account Assist Program?*

Yes

No

Which Account Manager assisted you in closing this account?*

First and Last Name

Would you like to...*

Activate Account

Account Information

Facility Name*

Implementation Date*

MM slash DD slash YYYY

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Date Activated*

MM slash DD slash YYYY

CMS ID / Clinic NPI*

Corporate Affiliation

Enter unlisted Corporate Affiliation

EMR Vendor*

EMR Vendor Name*

If unsure, indicate as UNKNOWN.

Address*

Street Address Suite City State ZIP Code

Phone*

Fax*

Office Contact

Email*

Missing Info Contact(s) to Add*

1

2

3

Missing Info Contact Name*

Missing Info Contact Email*

Missing Info Contact 2 Name*

Missing Info Contact 2 Email*

Missing Info Contact 3 Name*

Missing Info Contact 3 Email*

Sales Representative Name*

Sales Representative Email*

Sales Representative Cell

Sales Manager Name

Sales Manager Email

Sales Manager Cell

Accounts Payable Contact Name

Accounts Payable Contact Email

Accounts Payable Contact Phone

Name of Pharmacy Partner

Pharmacy Contact Name

Pharmacy Contact Email

Pharmacy Contact Phone

Portal Login User Setup

Click "+" to add additional users.

Email

Weekend Phone

First Name

Last Name

Physician Specialty*

Is this Urgent Care open 7 days a week?*

Yes

No

Do you want margins reported on Dysplastic Nevi?

Yes

No

Do you want margins reported on malignancies?

Yes

No

Do you want Mild, Moderate, or Severe grading on Dysplastic Neve?

Yes

No

Do you want Melanomas reported verbally to you?

Yes

No

Is it okay to verbally report Melanomas to staff?

Yes

No

Do you want second opinions on Melanomas, Sarcomas, and Lymphomas?

Yes

No

This account requires a signed facility agreement. Please reach out to your AVP to facilitate the next steps.

Shipping Details for Supplies

Ship to

Ship to Account

Ship to Sales Representative

Ship to Another Address

Ship to Address*

Street Address Suite City State / Province / Region ZIP / Postal Code

Sales Representative's Address*

Street Address Suite City State / Province / Region ZIP / Postal Code

ATTN*

Account Address*

Street Address Suite City State ZIP Code

Is this a trunk stock account?*

Yes

No

Select Lab (Kits & Labels)*

Vikor Scientific

KorPath

Provider Information

Providers*

If PA/NP, please list name of supervising MD. Click "+" to add additional providers.

Name (First Last)

Title

NPI

Provider Signature Attestation(s)

Drop files here or

Accepted file types: pdf, Max. file size: 25 MB.

Supplies

For any additional items or special requests, please leave a message in the NOTES box.

Kits

All kits include a requisition and the requested collection device unless a special request is made in the NOTES section.

Respira-ID™ (Nasopharyngeal)

Urine-ID™ (Urine Swab)

Urine-ID™ (Urine Swab AND Specimen Cup)

Toilet Hats (must be ordered separately from Urine kits)

Gastro-ID™ (General Swab)

Derm-ID™ (General Swab)

Derm-ID™ (TISSUE Kit)

Wound-ID™ (General Swab)

Wound-ID™ (TISSUE Kit)

Nail-Fungal ID (Swab)

Nail-Fungal ID (Tissue)

Surgical-ID (Swab)

Surgical-ID (Tissue)

Vaginal-ID™ (General Swab)

STI-ID™ (General Swab)

Pharmacogenetics (Buccal Swab)

Joint-ID™

EMA Workaround Labels

Urine/Vaginal Workaround Labels

Shipping Supplies

All shipping supplies are limited to 25 per order.

# of FedEx Labels

Please enter a number less than or equal to 25.

# of UPS Clinical Labels

Please enter a number less than or equal to 25.

# of Shipping Bags

Please enter a number less than or equal to 25.

Type of Shipping Bags*

To set up a pickup, regardless of label type, please visit our Pickup Request page.

Is this the first supply order for the account?*

Yes

No

Person Placing Order*

Email for Order Updates*

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Notes

Notes

Vanta Diagnostics is a molecular diagnostics company focused on Antibiotic Stewardship and tangible solutions for the practice of value-based medicine in the treatment of infectious disease.

22 WestEdge Street, Suite 800, Charleston, SC 29403
(854) 429-1069

Lab Locations:

22 WestEdge Street, Suite 800, Charleston, SC 29403
CAP #8359749 / CLIA #42D2150400
512 E. Township Line Rd, Suite 135, Blue Bell, PA 19422
CAP #8779637 / CLIA #39D2166771
3110 Cherry Palm Drive, Suite 340, Tampa, FL 33619
CAP # 2743001 / CLIA #10D0699501

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