Lab Order Form

Lab Order Form

Functional Medicine Labs & Self Pay Labs
Instructions

Please use this order form to order any Functional Medicine/Specialty labs that you wish to order. This is also appropriate to use for any self-pay labs or labs not covered by your insurance.

These tests are open to patients and non-patients; meaning, you do not have to be a patient to self-order these tests. If you are a patient, these will be reviewed with you at your follow up appointment. If you are not a patient, you can elect to have a consultation with our physicians to review any of the results and obtain a treatment plan (Rx plans are only available to patients of the practice but we can give recommendations).

Once you receive your kit, please schedule a lab draw appointment if your kit requires a blood draw. You can use the mobile phlebotomy or use one of the approved lab draw stations. You can find more information here:

https://support.rupahealth.com/article/1404-step-3-the-phlebotomy-options

Read more about the process here:

https://www.rupahealth.com/patients

You will NOT be able to take these tests to Labcorp or to Quest. Read the above directions, the directions that come with your kit or reach out to Rupa support.

There are times that are office is able to accomodate a lab draw. If you see a "Lab Draw/Services" option available on our scheduling site, that means we are taking lab appointments. Our fee is $35. If our schedule is full, you will not be able to schedule. In that case, please schedule with Any Lab Test Now or use a mobile phlebotomy service.

YOU DO NOT PAY FOR LABS AT THIS TIME. WHEN WE RECEIVE YOUR ORDER, YOU WILL BE CONTACTED BY THE LAB BY TEXT AND/OR EMAIL TO PAY THEM DIRECTLY. NO PAYMENT IS REQUIRED TO SUBMIT THIS ORDER FORM. THE LAB ALSO OFFERS PAYMENT PLANS!!

The following prices are before tax.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Are you a current/established patient of Dawson Integrative Medical Center? If not, that's ok-you can still order.

YESNO
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
FUNCTIONAL MEDICINE LABS
Please select the tests you wish to order (you will not be charged for these tests now; the lab will contact you to arrange payment directly & some even allow payment plans!)

Gut Health: US Biotek Advanced GI with H Pylori & Zonulin with Cultures $419Gut Health: Genova GI Effects Comprehensive Stool Analysis $479Gut Health: Doctor's Data Comprehensive Stool Analysis $299Gut Health: SIBO Trio Test $369Hormones: DUTCH Complete Hormone Panel Urine Test $350Hormones: DUTCH Plus $450Food Sensitivity: Alletess Food Sensitivity IgA Panel $180Food & Environmental Allergy: Diagnostic Solutions Allergy Explorer IgE $210Mast Cell Activation: Precision Point Intestinal Barrier Test $379Nutrient Panel: Genova NutraEval $479Nutrient Panel: Cell Science Systems Cellular Micronutrient Panel $249Nutrient Panel: Micronutrient from SpectraCell $399Nutrients: Micronutrient Panel from Cell Science Systems $250Nutrition: Nutritional Metals 16 Panel $115Neurotransmitter Panel: ZRT Labs Neurotransmitter $228Neurotransmitter & Adrenal Panel: ZRT Labs NeuroAdvanced $330Adrenal Panel: ZRT Diurnal Cortisol & Cortisol Awakening Response $138Adrenal Panel: DUTCH Complete Adrenal Panel $230Mold Testing: MicrobiologyDx Labs MARCoNS Testing $85Mold: Great Plains Lab Mycotoxin Test $310Heavy Metals: Doctor's Data Heavy Metal Test $129Genetics: PGx (Pharmacogenomic Testing) for Medication Response/Failure by TruDiagnostics $249Genetics Test: Blueprint 3x4 Genetic Testing $349Genetics: MTHFR Mutuation Analysis $115Methylation Panel: Genova $285MOAT: Microbial Organic Acid Testing $240OATs Testing: DUTCH OATS Testing $210Autoimmune: Access Medical Analyzer $149Immune: Viral Panel Premier by Immunosciences Labs $410Immune/Infections: Viral Screen Basic by Immunosciences Labs $230Infections: Lyme Disease Blot Panel $115Candida Immune Complex $125Personal Request (list whatever you would like below and we will give you pricing)Other
GENERAL LABS-SELF PAY LABS
These are for General Labs/Screening Labs (and great pricing for self-pay patients). Please select the tests you wish to order (you will not be charged for these tests now; the lab will contact you to arrange payment directly and some even have payment plans!) Please note there is a $50 lab fee PER order (not per test) if ordered at the same time if you are a current patient. If you are not a patient (just self-ordering labs), there is a $100 lab fee PER order (not per test).

Lipid Panel $9.00CMP (Comprehensive Metabolic Panel) $3.25Insulin $5.15A1c $5.15Urinalysis $5.00PSA (Prostate Specific Antigen) $5.15CBC w/PLT & DIFF (Complete Blood Count with Platelets & Differentials) $3.09TIBC (Iron Studies & Binding Capacity) $9.26Ferritin $5.15TPO (Thyroid Peroxidase) $5.15Thyroglobulin Antibodies $5.15TSH (Thyroid Stimulating Hormone) $5.15T3 Free $5.15T3 Total $5.15T4 Free $5.00T4 Total $5.00Reverse T3 $20.00Estradiol $7.20Total Estrogens $30.87Estrone $20.00Estriol $22.00FSH and LH $10.29SHBG (Sex Hormone Binding Globulin) $5.00Testosterone, Free, Total, BioAvailable and SHBG $15.00Testosterone, Total $5.15Testosterone, Free & Total and SHBG $10.00DHT (Dihydrotestosterone) $22.00Progesterone $5.00Prolactin $5.15Pregnenolone $35.00Amylase $1.50Lipase $3.09Cortisol $6.17DHEA-S $9.00Vitamin D 25 OH $20.58Vitamin B12 $5.15Vitamin B12 & Folate $10.29Magnesium, RBC $17.00ANA (Anti-nuclear antibody) $8.23CRP, HS (C-Reactive Protein, High Sensitivity) $8.23Sed Rate $5.00Stool Analysis $150.00STD Panel $33.00PT/PTT, INR $6.50Histamine $100.00Tryptase $42.50Homocysteine $10.00EBV Panel (Epstein Barr Virus) $69.00Immunoglobulin Panel $30.87Candida Panel $58.50Personal Request (list whatever you would like below and we will give you pricing)Other
Please allow 3 business days for us to process your order. We will submit your order to the appropriate lab.

YOU WILL RECEIVE AN EMAIL CONFIRMATION WHEN YOU SUBMIT THIS ORDER. IF YOU DID NOT RECEIVE AN EMAIL CONFIRMATION, THEN IT DID NOT GO THROUGH.
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Lab Order Form

FUNCTIONAL MEDICINE LABS

GENERAL LABS-SELF PAY LABS