Kit Request Form

Specimen collection kits and culture test can only be ordered by licensed practitioners, as recognized by the laws of the state of Pennsylvania. This includes: MD, DO, PA‐C, CRNP, DC, DPM or a certified nurse midwife.

Required fields are indicated with an asterisk.

*First Name: *Last Name: *Email: *Title: MD PA DO NP DDS DC DPM *Type of Practice: Medical *Address: Address 2: *City: *State: *Zip: Country: Only US-based physicians may order kits at this time. *NPI: Enter 10 Digit #. *Phone: Fax: *Kit Requested: Borrelia Kit  ENFD Kit  Toxicology *Toxicology Kit: 20 samples; with cups 20 samples; cups not included *Number of Kits Requested: Note: Toxicology kits are packaged in sets of 20. Please enter a value between 1-10. *How Did You Hear About Us? -- Please Select -- Internet Conference Colleague Referral ALS Sales Representative Other *Additional Information: Comments:   Security Code: