Test Kit Request Form

To send us a test kit request, simply fill in the details below and hit submit:

Note that fields marked with * are mandatory.
Name *
I am a: Clinician Patient
Address*
Email
Phone*
Referring Doctor's Name (* if you are a patient)
Referring Doctor's Phone (* if you are a patient)
Test Kits Required (and quantity) *
Include Biolab Request Form with Kits? Yes No
Bill referring Doctor for these tests? Yes No
Will patient submit payment along with the samples? Yes No