Patient Information

Clinician / Practice Information

Fee Payer Information

Clinical Information

Test Selection

MedScreen StaticMedScreen LiveGeneScreen

Specimen Requirements

All tests: One (1) EDTA Blood tube or saliva (in supplied collection kit).Please mark the specimen with both the patient’s ID number and name.

Current Medication / Supplements

Proposed/Future Drug Regimens

Lifestyle Factors for Pharmacogenomics Testing
AlcoholFoods/beverages containing caffeineFood/beverages containing cranberryFoods/beverages containing milkGrapefruit juiceMarijuanaSmokingAcidic foodsChamomile teasChocolateFermented food/saucesFoods containing liquoriceLeafy greensTonic waterFoods high in fatFoods high in proteinFoods high in sodiumFoods high in potassiumFoods high in ironFoods high in calcium