inFoods IBS - Website Payment Portal

Payment Portal
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
This test is not offered in the State of New York.
Gender*

MaleFemaleUnknownOther
Dx Code:*

K58.0
Test Code:*

IBS100TMEDIBS
Email*
JohnDoe@example.com
Phone Number*
How did you hear about us?*
Notes
Any notes that you want communicated about your ordering physician.
Authorization and Consent for Diagnostic Testing*

I understand that there are risks and benefits associated with undergoing a diagnostic screening testing and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I further acknowledge the following:
I am the individual who will provide the sample for the Test(s) that I am requesting or I am the parent or legal guardian of a minor who is providing the sample for testing.I am at least eighteen (18) years of age.I currently do not have a diagnosed eating disorderI am not experiencing unexpected blood in the stool. (not hemorrhoids)I have not been experiencing unexpected weight loss.I have read and understand the information provided about the Test(s) that I have been provided on the website where I requested the Test.The information I have provided in connection with my request to CWI is correct to the best of my knowledge. I will not hold or its employees or agents responsible for any errors or omissions that I may have made in providing such information.My health information and results may be shared with CWI employees and agents for the purpose of ordering, processing, and reporting my results.Medical Services provided by CWI are purely for diagnostic assistance purposes and do not create a physician-patient relationship, and do not constitute medical care or diagnosis or treatment of any condition, disease, or illness.I authorize CWI to contact me via text message to communicate with me regarding my test.
Please note: Refunds are available only for unprocessed samples. See Refund Policy for details.

My Products*

inFoods IBS$390.00

Enter coupon

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Card Holder Email*
JohnDoe@example.com
Should be Empty: