Victus88 Test Kit with Consultation Order Form

Victus88 Test Kit with Consultation Order Form

Please fill out this form completely, providing all required patient and shipping information. 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
  • Review & Place Order

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:
Would you like to order more than one 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:
Will this test kit be shipped to the same address?
Shipping Address for this Test Kit:
Shipping Address for 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.