GAL-3 Function DNA Report

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Clinic Name*

Contact Phone*

Please enter a contact number in case we need to contact you directly.

Physician Name*

First Last

Email*

Important! You must enter the Sample ID barcode number on collection tube when registering your patient.

Patient ID

Use this field to enter your patient ID or alternatively their name.

Patient DOB*

Please enter the patient's Date of Birth

DNA Collection Tube Barcode*

Enter the 12-digit barcode from the tube. You will not be able to complete this order without the Sample Barcode ID.

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TB006 DNA Lab Fee*

Price:

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Quantity

Total

Credit Card*