Please submit one PGx Test request per patient.  Medications and additional contact information may be provided in the Message Box.

If you are requesting this test on behalf of the patient, please provide your contact information.

Patient Information
Patient Name: *
Patient Name:
Contact Name:
Contact Name:
(If different than patient)
Phone: *
Phone:
Alternate Phone: (optional)
Alternate Phone: (optional)
Physician Information (if available)
Name of Primary Care Physician:
Name of Primary Care Physician:
Physician Telephone:
Physician Telephone:
Testing Location:
Preferred Test Location: *
Additional Information