Provider Collection Request

To have a collection kit sent to one of your patients, please fill in this form as completely as possible. An ION representative will contact you with any questions. Thank you for selecting ION Diagnostics as your laboratory of choice.

Provider Email *

Provider Practice Name *

Provider Contact Name *

Provider Contact Phone *

Patient First Name *

Patient Last Name *

Patient Contact Phone Number *

Date of Birth *

Street Address *

Street Address 2 *

City *

State *

Zip *

Insurance Demographics Carrier and ID Number *

Check Test To Be Performed

COVID-19 PCR

Strep PCR

UTI PCR - Urine

STI PCR - Urine

Wound Care PCR

Diagnosis Code *

Do you have a copy of this order in your patient's medical record? *

Yes No