Patient Information

[acceptance* patient-signature] I confirm that the above information is true and correct. (This will serve as the digital signature of the patient/guardian.)

Clinician / Practice Information

[acceptance* clinician-signature] Clinician acknowledges responsibility for submitted information. (This will serve as a digital signature.)

Fee Payer Information

Test Selection

Pharmacogenomics STATICPharmacogenomics LIVENutrigenomics PremierNutrigenomics Standard

Specimen Requirements

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

For Laboratory Use Only

Received by: ___________________________

Date Received: _________________________

Sample ID: _____________________________