CDD - WLR Account Request Form

Account Request for Web-based Laboratory Reporting (WLR)

Instructions

Please answer the questions as fully as possible. Contact information (contact name, email, phone) is critical and must be accurate in order to complete the WLR Account activation. WSLH staff will contact you using this information to complete and verify your WLR account. NOTE: Required fields are indicated by asterisk (*). This is a manual process and may take several days to complete. At that time you will receive an email with instructions on the next step in this process. Please watch for this email and make sure it does not end up in your SPAM folder.

Add/Delete/Change

Type of Request(Required)

Is this a request to Add a new WLR Account, to Delete an existing WLR account, or to Change an existing WLR account?

Add New Account

Delete Existing Account

Change Existing Account

WLR User Information

Name(Required)

First Middle Last

Contact Phone Number(Required)

Contact Email Address(Required)

Enter Email Confirm Email

Best time to call(Required)

WSLH IT will contact the User to set up their account, what is the best time to call?

Laboratory Information

Laboratory Name(Required)

Laboratory Address(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Laboratory Phone Number(Required)

Laboratory CLIA Number(Required)

Laboratory Supervisor/Manager Name(Required)

Please list test(s) that will be performed at your site (exclude test sent out to another facility):

Test Name

Manufacturer

Type of Test (antigen, antibody, PCR, rapid molecular, etc.)

LOINC Code (if known)

Verification