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Victus88 Test Kit with Consultation Request Form

**Victus88 Test Kit with Consultation Order Form

Please fill out this form completely, providing all required patient and shipping information. Be sure to indicate the type of sample collection you prefer so we can send the correct test kit. Then enter your credit card information and accept the user agreement to place your order. Your test kit will arrive within 5-7 business days. NOTE: Unique patient information must be entered for each test kit that you order.

  • Patient & Shipping Information
  • Payment Information
  • Order Summary / Request Consult

PRIMARY PATIENT INFORMATION

Please provide the primary patient information. Unique patient information must be entered for each additional test kit you order. All fields are required.
Primary Patient Name:
Primary Patient Name:
Sex:
Primary Shipping Address:
Primary Shipping Address:
Please select your preferred blood sample collection method for this test kit:
* Additional fees will apply for blood draws.
Would you like to order an additional test kit?

ADDITIONAL TEST KITS

If ordering 10 or more test kits, please contact Biovision Diagnostics Client Services at help@biovisiondx.com or call (618) 690-9555.
Additional Patient Name:
Additional Patient Name:
Sex:
Please select your preferred blood sample collection method for this test kit:
* Additional fees will apply for blood draws.
Will this test kit be shipped to the same address?
Shipping Address for this Test Kit:
Shipping Address for this Test Kit:
plus 3 Add Another Test Kit minus3 Remove This Test Kit

If you have any questions or require assistance with completing this form, please contact Biovision Diagnostics Client Services at help@biovisiondx.com or call (618) 690-9555.