inGENEious RX Pharmacogenomics Testing Request Form

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Thank you for choosing inGENEious RX for your pharmacogenomics testing.

The cost for the pharmacogenomics test is $195.
You will be emailed an invoice once your request form has been received and processed.

You will also be emailed a HIPAA release form via DocuSign for your electronic signature. This HIPAA release form authorizes the pharmacogenomics laboratory to release your test results to the inGENEious RX pharmacist.

Your test collection kit will be shipped from the laboratory to your preferred address. The kit will contain detailed instructions on how to properly collect your DNA sample using a simple cheek swab. Please mail the test kit back to the lab for processing. The test will not be processed until your invoice has been paid.

After approximately 3 weeks, an inGENEious RX pharmacist will contact you to review your test results and answer any questions you may have.

**If you would like to order a test kit for more than one individual, please fill out a separate request form for each individual.
**Each individual will be required to sign his/her own HIPAA release form unless a medical power of attorney is in place.
If a medical power of attorney is in place, please email to geneiousrx@gmail.com.
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Email *

Full Name *

Phone Number *

Address to which test kit should be shipped *

I acknowledge by typing my name below that this pharmacogenomics test is a "direct access test" provided to me without a prescriber's authorization and it may not be reimbursed if submitted to my healthcare insurance for payment. *

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