Mirum NBS Reflex - Kit Ordering - PreventionGenetics

Kit Order Form

Clinical Testing kits are provided as a courtesy.
There is no charge when ordering kits.
Kits will include pre-paid return postage.
Kit requests may take up to 1 week for delivery.

Kits are being sent to

Healthcare Provider Patient

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 SP101.

Blood specimens are always preferred. However, buccal collection kits are also available.

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: *

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

Mirum Kit Order Form

Kit Order Form

Kits are being sent to

Kit Selection

Contact and Shipping Information