Order Form Patients

Exa Test™

Non-invasive Intracellular Tissue Analysis for:

Mg Ca P K Na Cl

Magnesium Calcium Phosphorus

Potassium Sodium Chloride

Patients, you will need a healthcare provider who has agreed to collect the specimen and provide you with follow up interpretation support.

If you do not have a healthcare provider, you may request physician information in the message box below.

All specimen collection kits are shipped to your healthcare provider. If you live at a great distance from your provider such as a rural area or are homebound, we can send you the specimen collection kit but only with a prescription.

All test results are sent to the healthcare provider within one to two days from receipt of specimen at our laboratory. Your provider will review results in view of your medical history and prescribe treatment protocol. IntraCellular Diagnostics cannot provide you any medical support. IntraCellular Diagnostics can discus your results only with your physician.

IntraCellular Diagnostics provides interpretation and treatment protocol support to healthcare providers only.

You may call or email us anytime if you have any other questions.

Enter your healthcare provider's contact information below, and we will ship a specimen collection kit to him/her on your behalf.
If your physician is not familiar with the EXA procedure, we will include literature, collection information and provide training by phone.

Health Care Providers: For urgent shipping, please call 541-245-3212

Providers' contact information:

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Last Name

Middle Initial

Degree/Description

Title

Organization

Practice Specialty

Office Phone

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E-mail

Web Site

SHIPPING	ADDRESS
Street Address
Address (cont.)
City
State/Province
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Patient's contact information:

Patient First Name
Patient Last Name
Patient E-mail/Tel.
Patient Zip Code

You may order the items below at no cost to physicians in the USA.

For international orders use the message window below to request the shipping and

handling fees for your country.

Please select:

Literature (includes research)

Specimen Collection Kit: Starter of 5 Slides for 5 tests

Enter additional messages below:

Please Contact Me

E-mail: patientservices@exatest.com

First Name
Last Name
Middle Initial
Degree/Description
Title
Organization
Practice Specialty
Office Phone
FAX
E-mail
Web Site