Client Registration New Client Registration Organization Name* Office Contact* Phone*Fax*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ordering Providers & AuthorizationProvider Name* First Last NPI #* Provider Name First Last NPI # Provider Name First Last NPI # Provider Name First Last NPI # Provider Name First Last NPI # Consent* I hereby authorize Solaris Diagnostics and its partners to test, results, and bill all the requisitioned patients 95523