ION Diagnostics | 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 Information

Provider Email

Provider Practice Name

Provider Contact Name

Provider Contact Phone

Patient Information

Patient First Name

Patient Last Name

Patient Contact Phone Number

Date of Birth

Home Address for Collection

Street Address

Street Address 2

City

State

Zip

Insurance Demographics Carrier and ID Number

Sample Information

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