Provider Service Agreement*

Medical Questionnaire

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.

By checking this box, I to agree to the statement above.

Physician Information

Physical Location

Street Address

Address Line 2

City

Zip Code

State

Country

Physician Signature

Date

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.

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