Physician's Enrollment Form

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Clinic/Facility Name: *

Address: *

City: *

State: *

Zip code: *

Phone: *

Fax:

Physician Authorization

I acknowledge this form will be used to create my unique login for Apollo Web Portal which will be used to electronically sign patient orders in accordance with CMS requirements. I authorize Mako Medical Laboratories to perform testing on patients from my practice as indicated on individual laboratory service requisition forms and individually signed within Apollo Web Portal.

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Physician Name: *

NPI # : *

Physician's Email: *

Mobile Number: * 🛈

Signature : *

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Date: