Physician's Full Name(required) Facility(required) Facility Phone Number(required) Facility Address(required) City State Zip/Postal Code Country Special Instructions Covid 19 Test None 5 10 15 20 25 30 35 40 45 50 Respiratory Pathogen Panel None 5 10 15 20 25 30 35 40 45 50 Allergy Test None 5 10 15 20 25 30 35 40 45 50 Cancer Genetics Test None 5 10 15 20 25 30 35 40 45 50 Cardiac Genetics Test None 5 10 15 20 25 30 35 40 45 50 Diabetes/ Obesity Panel None 5 10 15 20 25 30 35 40 45 50 PAD Test None 5 10 15 20 25 30 35 40 45 50 Pharmacogenomics Panel None 5 10 15 20 25 30 35 40 45 50 Toxicology Test None 5 10 15 20 25 30 35 40 45 50 Urinary Tract Infection None 5 10 15 20 25 30 35 40 45 50 Submit Δ