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).

READ IMPORTANT INFORMATION HERE:

For routine blood work, we use Evexia (Labcorp). Evexia will contact you via text and/or email to arrange payment. Once you have made payment to Evexia, they will send you a paid lab order that you will take to Labcorp. We recommend scheduling an appointment and not walking in. You will not have to pay anything at the lab since you have already pre-paid. No kits are shipped to you; you simply take the Labcorp order with you.

For Specialty Functional Medicine Labs, we use RUPA. These are tests like stool testing, mold testing and non-routine blood work. Rupa will contact you via text and/or email to arrange payment and to ship your kit directly to you. If your test is not an at-home collection (stool, urine, salivia), you will need to take your lab kit to an independent draw station like AnyLabTest Now OR you can use a moible phlebotomy service and there are likely additional draw fees. You cannot take the kit to traditional labs like Quest or Labcorp. You can find more information here:

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

https://www.rupahealth.com/patients

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 and are subject to change (we do not control the lab pricing).

This lab order will be reviewed, approved and processed by Dr. Christina. Please allow 3 business days for her to do so. Our business hours are Monday-Thursday 9am-4pm. Orders are not processed outside of business hours. If you require URGENT labs, please do not use this order form and instead go to your nearest lab with an official lab order and you will pay them directly (you will NOT receive our self pay discount). We encourage you not to wait until the last minute to order labs.
Name (This must match the patient name ONLY. If there is more than 1 patient, each needs their own order)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
STOP! Did you put the patient name on this order? It must match the patient name only. Also, remember if you are ordering for multiple people, each needs their own order form.

I agree
RUPA SPECIALTY 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!) Once payment is made, Rupa will mail you a lab kit.
Gut Health/Microbiome Specialty Functional Medicine Testing

Gut Health: US Biotek GI-Advanced GI with Zonulin & H-Pylori (stool) $419Gut Health: Genova GI Effects Comprehensive Stool Analysis 1 Day Collection (stool) $479Gut Health: Diagnostic Solutions GI-Map (stool) $403Gut Health: Doctor's Data Comprehensive Stool Analysis(stool) $299Gut Health: Gemelli Trio-Smart SIBO Breath Test (breath) $369Gut Health: Genova SIBO 3 Hour Breath Test (breath) $295Gut Health: Doctor's Data Yeast Culture/Sensitivities (stool) $125Gut Health: Mosiac Diagnostics MOAT-Microbial Organic Acid (urine) $339Oral/Gut Health: Bristle Health Oral Microbiome (saliva) $204Vaginal Microbiome: US Biotek Vaginal Microbiome Profile (vaginal swab) $224Personal Request (list whatever you would like below and we will give you pricing)Other
Hormones, Adrenals, Neurotransmitter Specialty Functional Medicine Testing

Hormones: DUTCH Complete Dried Urine (dried urine) $375Hormones: DUTCH Plus (urine & saliva) $482Neurotransmitter Panel: ZRT Labs Neurotransmitters (urine) $228Neurotransmitter & Adrenal Panel: ZRT Labs Neurtransmitters + UDH I (urine) $298Adrenal Panel: ZRT Diurnal Cortisol (saliva) $145Adrenal Panel: DUTCH Adrenal Panel (dried urine) $250Personal Request (list whatever you would like below and we will give you pricing)Other
Allergies, Sensitivities, Immune, Autoimmune Specialty Functional Medicine Testing

Food Sensitivity: Alletess 96 IgA Food Sensitivity Panel (blood)$192Food & Environmental Allergy: Diagnostic Solutions IgE Allergy Explorer (finger stick) $229Food Sensitivity & Allergy Panel: Alletess 96 IgG Food Sensitivity & 15 Common IgE Combo Panel (blood) $293Food Sensitivity: KMBO FIT 22 (blood spot) $161Mast Cell Activation: Precision Point Advanced Intestinal Barrier Assessment (blood) $412Autoimmune: Access Med Autoimmune Analyzer (blood) $184Immune/Infections: Access Med Epstein-Barr Evaluation (blood) $150Immune/Infections: Immunosciences Lab Viral Panel Premier (blood) $439Immune/Infections: Immunosciences Lab Long COVID Panel (blood) $578Immune/Infections: Immunosciences Labs Viral Screen (blood) $247Immune: Access Med Immunoglobins Panel (blood) $105Infections: Access Med Lyme Disease Antibodies with Reflex to Blot IgG IgM (blood) $107Infections Tick: Alletess Tick-Bite Induced Meat Allergy (blood) $204Personal Request (list whatever you would like below and we will give you pricing)Other
Nutrient & Genetic Specialty Functional Medicine Testing

Nutrients: Genova NutraEval Plasma (blood & urine) $525Nutrients: Cell Science Systems Cellular Micronutrient Assay (blood) $267Nutrients: Spectracell Micronutrient Test (blood) $427Nutrients: Boston Heart DBS Nutrition & Wellness (blood spot)$213Nutrients: Access Med Nutritional Metals 16 Elements (urine) $145Genetics: PGX Pharmacogenomic Testing for Medication Response/Failure-TruDiagnostics PgX (swab) $280Genetics Test: 3x4 Genetics 3x4 Genetics Test + Blueprint Report (swab) $374Genetics/MTHFR: Cell Science MTHFR (swab) $125Genetics/MTHFR: Cell Science MTHFR (blood) $125Genetics/Methylation: Genova Methylation Panel (blood) $309OAT Testing: Mosaic Diagnostics Organic Acids OAT (urine) $320MOAT Testing: Mosaic Diagnostics Microbial Organic Acids MOAT (urine) $240Personal Request (list whatever you would like below and we will give you pricing)Other
Mold & Heavy Metal Specialty Functional Medicine Testing

Mold Testing MARCoNS: MicrobiologyDx Labs MARCoNS Testing (nasal swab) $125Mold Mycotoxin: Mosiac Diagnostic MycoTOX (urine) $332Mold: Access Med TGF-B1 (blood) $210Mold: Mosiac Diagnostics Mold IgE Allergy Test (blood) $231Heavy Metals: Doctor's Data Urine Toxic Metals Random (urine) $145Personal Request (list whatever you would like below and we will give you pricing)Other
EVEXIA (LABCORP) 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; Evexia will contact you to arrange payment directly). Once payment is made, Evexia will send you a Labcorp order form and you are able to make an appointment at Labcorp. No kit is sent to you.

Lipid Panel $9.00CMP (Comprehensive Metabolic Panel) $8.00Insulin $10.00A1c $8.00Urinalysis $5.00PSA (Prostate Specific Antigen) $11.00CBC w/PLT & DIFF (Complete Blood Count with Platelets & Differentials) $6.00Candida IgG, IgA, IgM Antibodies $53.00TIBC (Iron Studies & Binding) WITH Ferritin $12.00TPO (Thyroid Peroxidase) & TG (Thyroglobulin Antibodies) $14.00TSH (Thyroid Stimulating Hormone) $6.00T3 Free $10.00T3 Total $7.00T4 Free $8.00T4 Total $5.00Reverse T3 $23.00Estradiol $14.00Total Estrogens $25.00Estrone $34.00Estriol $16.00FSH and LH $22.00SHBG (Sex Hormone Binding Globulin) $16.00Testosterone, Total $10.00Testosterone, Free & Total $27.00DHT (Dihydrotestosterone) $40.00Progesterone $13.00Prolactin $9.00Pregnenolone $40.00Amylase & Lipase $13.00Cortisol morning $11.00DHEA-S $15.00Vitamin D 25 OH $18.00Vitamin B12 $9.00Vitamin B12 & Folate $13.00Magnesium, RBC $10.00ANA (Anti-nuclear antibody) $9.00CRP, HS (C-Reactive Protein, High Sensitivity) $12.00Sed Rate $7.00Histamine, whole blood $21.00Tryptase $85.00Homocysteine $18.00IgE, total $10.00Iodine, $40.00Selenium, $22.00Zinc, RBC $14.00FEMALE Complete Functional Medicine Panel from Evexia-Labcorp (CRP, CBC, CMP, Cortisol morning, DHEA-S, Estradiol, Ferritin, FSH & LH, A1c, T3 Free, T3 Total, T4 Free, T4 Total, Testosterone Total, TGA, TPO, TSH, Vitamin B12 & Folate, Vitamin D 25 OH, Insulin, Iron TIBC, Lipid Panel, Magnesium RBC, Progesterone, Urinalysis) ~$230.00 (you make payment to Evexia and then schedule with Labcorp)MALE Complete Functional Medicine Panel from Evexia-Labcorp (CRP, CBC, CMP, Cortisol morning, DHEA-S, Estradiol, Ferritin, A1c, T3 Free, T3 Total, T4 Free, T4 Total, Testosterone Free & Total, PSA, TGA, TPO, TSH, Vitamin B12 & Folate, Vitamin D 25 OH, Insulin, Iron TIBC, Lipid Panel, Magnesium RBC, Urinalysis) ~$230.00 (you make payment to Evexia and then schedule with Labcorp)Personal Request (list whatever you would like below and we will give you pricing)Other
This lab order will be reviewed, approved and processed by Dr. Christina. Please allow 3 business days for her to do so. Our business hours are Monday-Thursday 9am-4pm. Orders are not processed outside of business hours. If you require URGENT labs, please do not use this order form and instead go to your nearest lab with an official lab order and you will pay them directly (you will NOT receive our self pay discount). We encourage you not to wait until the last minute to order labs.

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.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Lab Order Form

RUPA SPECIALTY FUNCTIONAL MEDICINE LABS

EVEXIA (LABCORP) GENERAL LABS-SELF PAY LABS