To begin ordering tests from AccessDx Laboratory, please fill out the following form, and our team will contact you within three business days.
For immediate assistance, please contact [email protected].

If you are not ready to begin testing your patients, and have more questions, please complete our Contact Form .

Please enable JavaScript in your browser to complete this form.

Provider Information

Name *

First

Last

Organization Type

• Hospital / Health System
• Long-Term Care Community
• Pharmacy / Consulting Pharmacist
• Practice
• Provider
• Other

Organization Name

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Address Phone Information

Test Type *

• AccessDx Pharmacogenomics (PGx) Profile

Ordering Preference *--- Select Choice ---ElectronicPaper

Billing *--- Select Choice ---Client Bill ($350)Insurance BillBoth

Administrative Contact (optional)

Name

First

Last

Title

Email

Phone

Next Steps:

1. AccessDx Laboratory Sales Operations will send you a Client Intake Form and Business Associate Agreement from [email protected] via AdobeSign.
2. Please review, sign, and submit both forms.
3. AccessDx Laboratory Sales Operations will send you the fully executed forms once complete.
4. You will be contacted by an AccessDx Laboratory team member for questions, kit requests, and portal training (if electronic ordering is selected).

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