REGISTER YOUR PGx KIT

REGISTER YOUR KIT

Must be completed before sending your sample to our laboratory.
Kit ID*
13-Digit ID found on the side of your kit and on the back of the instruction booklet.
You have entered an incorrect Kit ID. The Kit ID can be found on the side of your kit or on the back of the instruction booklet. If you need further assisatnce please contact us at, customercare@patientschoicedirect.com.

Patient Contact Information

Provide the following fields in case we need to contact you regarding your test.
Patient Name*

First NameMiddle NameLast Name
Email For Results To Be Sent To*

Confirmation EmailResults will be sent to this email.
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Demographics

Provide the following fields so we can provide you with the most detailed report.
Date of Birth*

MonthDayYear
Biological Gender*

MaleFemale
Race
This field is optional, however is encouraged for a more detailed report.
Hispanic Ethnicity
This field is optional, however is encouraged for a more detailed report.

Patient Questionnaire

Please provide the following fields so we can analyze your results.
What medications are you currently taking? (Select all that apply)
List additional medications you are currently taking that are NOT listed above.

Collect Your Sample

Follow Step B in your instruction booklet to properly record and collect your sample.
I have written in pen, my name and date of birth on both tubes.*

Yes, I verify I have completed this step.
Barcode ID*
13-Digit ID located on the tube of the swabs.
Time Sample Was Taken*

AM/PM Option
Date of Collection*

MonthDayYear

Patient Consent

Must be completed to receive your results.
Patient Consent*
Signature*

Clear
Date*

MonthDayYear
Should be Empty: