Order Form

Order Form

Please make sure to fill in the required fields and submit this form to complete your order to stock your clinic.
inFoods IBS - Self-Collection Kits - (P#: 1705) - Must collect payment before handing test to patient *
1 Kit contains all necessary components to complete one sample collection at home.
inFoods IBS - In-Office Collection Kits - (P#: 1703)*
1 Kit includes 8 sample collection kits, return shipping labels and shipping boxes for each respective test.
Ordering Clinic Name:*
Office Contact Number*
Office Contact E-mail*

Confirmation EmailEmail of the person who will receive the materials and maintain stock.
Ship to:*

Key Account ManagerMedical Practice / Business Address
Key Account Manager*

Aaron GreenbergBryan DerricksonEva KarvounisJon Richardson
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Special Instructions:
Special Instructions:
Should be Empty: