DUTCH Test International Request Form

DUTCH Test International Request Form

Kindly provide the following information. Each DUTCH test kit and review costs $475 USD and we can have them shipped to most countries. After you fill out this form, we will send you a PayPal invoice for the amount due. (If, for some rare reason, we are not able to ship to your country, we will reach out via email to let you know.)
Name of patient *

First Name Last Name
Name of parent/guardian (if applicable)

First Name Last Name
Main Email for Contact *
Phone Number *

Area Code Phone Number
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient date of birth *

Month Day Year
Date
We will be sending you a PayPal invoice via email for $475.
- If you have a PayPal account , please provide us with the email address that you use to login to PayPal.
- If you don't have a PayPal account , that is fine. You will be able to click "Pay with credit or debit card" on the invoice and pay that way, without an account.
Email address where we should send the $475 invoice *
example@example.com
Other Notes (Optional)
Should be Empty: