Akouos Resonate - Kit Ordering - PreventionGenetics

Kit Order Form

There is no charge when ordering kits.
Kits will include pre-paid return postage.
Kit requests may take up to 1 week for delivery.

Kit Selection

If your patient has had a bone marrow transplant or recent blood transfusion, the above kit types may not be recommended. Please contact us for further details, referencing SP316.

Kits are being sent to

Healthcare Provider Patient

Contact and Shipping Information

* - Denotes a required field. We can accept a P.O. Box address only for one or two kit orders.

PROVIDER INFO

First Name: *

Last Name: *

NPI (required for US healthcare providers): *

Institution:

E-mail: *

Phone: *

SHIPPING INFO

Patient First Name: *

Patient Last Name: *

Patient Phone Number:

Street Address: *

Address 2:

City: *

State/Province:

Zip Code: *

Country: *

Comments:

Return Shipping Method