Healthcare Provider Account Registration

Healthcare provider accounts are intended for healthcare providers, practitioners, organizations, and other professionals who plan to use VCSTest.com with patients or clients.  In-office testing is fee-based, whereas testing for referred patients is free or by donation.

If you are an individual or patient, please register using our Individual/Patient Registration Form.

To register for a healthcare provider account, please fill out and submit the registration form below.   Fields outlined in red are required.
Required Information
  
  
  
  
Choose Account Type:  


Optional Information
Optional information will be used for greetings, to identify your results, and for research purposes, and will not be shared or used otherwise.
Practice/Organization Information
Please provide the following practice/organization information.
Organization Information
Please provide the following information for the organization conducting the research.
  
  
  
  
  
  
  
  
  
  
  
Practitioner Information
Please provide the below information for the practitioner who will be using the test.  If your organization has multiple practitioners and you'd like to have them listed as referrers individually, please contact us after registering.
Researcher Information
Please provide the following information for the researcher who is primarily responsible for the research or for using VCSTest.com.
  
  
  
  
  
Research Information
Referring Healthcare Provider
If you were referred to the site by your healthcare provider and would like to share your test results with them, please choose their name from the dropdown list (you can search the list by typing after you've clicked the dropdown):
  
If your referrer isn't listed here, please let us know so we can contact them and add them to the list.

(Note:  If you are a healthcare provider and would like to be listed here so you can receive patient test results directly from VCSTest.com, please register using our Healthcare Provider Registration Form.)
Verify
Please verify that you're human by entering the text you see in the image below.

   
Acknowledgement(s)