User Registration - IMMUNO-COV™

Company name *

Street address *

City *

State *

Zip *

PAYMENT INFORMATION

Your payment contact is responsible for providing payment information upon Imanis’ receipt of your orders. Payment may be made via credit card or ACH, you will be contacted by Imanis for payment preference. All orders must be submitted via the Portal by uploading a completed Shipping Manifest (blank manifests may be found in the Portal). The payment contact will not be granted Portal access unless designated as a Portal User. See Portal Access information below for additional details.

Payment contact first name *

Payment contact last name *

Payment contact email *

Payment contact phone *

PORTAL ACCESS

The IMMUNO-COV™ Portal is the place for customers to download IMMUNO-COV™ instructions and documents, submit orders, and review test results. Provide details below for all individuals you wish to have access to the Portal. Registered users will receive an email containing their unique username and a temporary password, plus additional instructions on how to access the Portal and update login credentials.

- Portal User 1

First name *

Last name *

Email *

- Portal User 2

First name

Last name

Email

- Portal User 3