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.

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.
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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!)
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: Access Labs Candida Albicans IgG, IgA, IgM (blood) $135Gut 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
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 $10.00FEMALE Complete Functional Medicine Panel (ANA, CRP, CBC, CMP, Cortisol, 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) $278.00MALE Complete Functional Medicine Panel (ANA, CRP, CBC, CMP, Cortisol, DHEA-S, Estradiol, Ferritin, A1c, T3 Free, T3 Total, T4 Free, T4 Total, Testosterone Free, Bioavailable & Total, DHT, PSA, TGA, TPO, TSH, Vitamin B12 & Folate, Vitamin D 25 OH, Insulin, Iron TIBC, Lipid Panel, Magnesium RBC, Urinalysis) $306.00Personal 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

SPECIALTY FUNCTIONAL MEDICINE LABS

GENERAL LABS-SELF PAY LABS