Provider Service Agreement*
I accept responsibility for all tests ordered from my office/clinic that are sent to ImmunoGenomics Laboratory. I will still provide a requisition with each sample, which should be deemed as my written request to perform each specified test. I will inform ImmunoGenomics Laboratory, at 1-281-846-1998, if I would like to end this electronic authorization agreement.
Please fill out the following form to help us understand your physical condition.
ImmunoGenDX Laboratories Portal Access Request
To ensure privacy of patient information and correct delivery of patient reports to the proper individuals, please provide all of the following information regarding the requesting medical office. This is to ensure that the information we have on file is correct and to verify account details for registered accounts. This request may be extended to cover additional locations or emails in the future. For additional assistance, contact info@Immunogeno.com.