Easy and quick genetic testing for medication.

Customer support / orders: (888) 383-2181

At Home PGx Test
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Medication List
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Provider Portal

Order a kit

Online form · self-pay

Standard new order — PGx requisition form

Complete all four sections. Patient and prescriber details are required before the laboratory can process a sample.

COLA ID 33822 · CLIA ID 45D2288954 · (888) 383-2181 · [email protected]

"*" indicates required fields

Patient information

First name*

Last name*

Street address*

City*

State*

ZIP*

Email*

Phone*

Date of birth*

Preferred language

Gender*

Ancestry

Select all that apply.

African American

Hispanic

East Asian

Caucasian

Pacific Islander

South Asian

Native American

North African

Other

Medical history

Diagnosis code(s)*

Current medication(s)

Considering medication(s)

Requested PGx test

Test for all genes

Test for all genes listed below

Or select individual genes to test

ABCG2

APOE

BCHE

CYP2B6

CYP2C19

CYP2C9

CYP2C

CYP3A4

CYP3A5

CYP2D6

CYP4F2

DPYD

G6PD

MT-RNR1

NAT2

NUDT15

SLCO1B1

TPMT

UGT1A1

VKORC1

Prescriber information

Prescriber's name*

Office contact name

Practice address*

City*

State*

ZIP*

NPI #*

Physician license #*

Phone*

Fax

Prescriber signature (type full name)*

Date*

Disclaimer

By signing this form, the patient and/or authorized prescriber certifies the accuracy of the information provided and authorizes RPhLabs to perform the requested testing. Test results are for use by a licensed healthcare provider only, and the responsible party acknowledges financial responsibility for applicable charges.

Disclaimer agreement*

I have read and agree to the disclaimer above.*

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Pharmacogenomic testing informs prescribing. It does not diagnose disease and does not replace medical advice. Never change a medication without your clinician.