Radiance -IncellDx_OrderForm

Sender Email
info@theradiancediagnostics.com
Client ID
Patient ID
Are you a Physician or a Patient?*

PhysicianPatient
Physician Name (Last, First)
Physician NPI:
Physician Address:
Physician Email/Fax/Phone:
Patient Email*
example@example.com
Last Name
First Name
Birthdate*

MonthDayYear
Gender

MaleFemale
Patient Phone*
Address for Shipping the Test Kit*

Address

Address 2

CityState

Zip Code
Country*
Shipping to Canada requires additional shipping fee, select "Yes" if you agree and "No" if you disagree. When shipping internationally to Canada, there are additional fees and paperwork required to comply with customs regulations. As a result, we are obligated to include an extra charge of $90 to cover these expenses.

YesNo
Oops!

We are sorry but this order cannot be processed.

Important Notice for Canadian Orders:
Please note that an additional shipping fee applies to orders shipped to Canada. If you do not agree with this additional cost, the order cannot proceed.

Thank you for considering our products, if you would like to proceed, feel free to refresh this page.
This form is for North America only. If you are not from either United States or Canada, this form can not be submitted.

Thank you!