Healthcare Professional (Affiliate) Registration

If you have already completed this step please click here to login and complete the onboarding process.

Required*

Business Name / Sole Proprietor*

Below is your unique account url which you can provide as an option to your patients to purchase tests from the comfort of their home. Please submit your request that best represents your business. If your business has a website it is recommended that you use your domain name (excluding the www. and .com) instead of your business name. Note: Use lowercase letters and numbers ONLY, no spaces or symbols are allowed.

Account Url*

www.ultalabtests.com/

Account Administrator

First Name*

Middle Initial

Last Name*

Title

Office Phone

Fax Phone

Address 1*

Address 2

City*

Country*

State*

Postal Code*

The email address and password you enter below will be used to access your Portal where you will be able to place and track your orders and manage your account.

Confirm Email

Password

Confirm Password

Password Requirements:

Must be at least 8 Characters long
Must include 1 Upper Case letter
Must include 1 lower Case letter
Must include 1 number
Must include 1 special character @ # ? ! $ % ^ & * -

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