Checkout – Additional Information

Additional Fields

Patient First Name *

Patient Last Name *

Country *

Postcode *

Patient Address Line 1 *

Patient Address Line 2 (optional)

Patient Address Line 3 (optional)

Town/City *

Patient Date of Birth *

Sex * Male Female

Do you need a test collection kit sent? (If you are drawing blood at a center who holds kits, please select no) * Yes No

Order Notes. For any special notices regarding this order please contact the logistics department on 02039954197 and email logistics@functionaldx.com (optional)

Patient Email *

Patient Contact Number *

By ticking this box you agree to and accept the terms and conditions of sale and understand that this order is to be completed within 90 days from this order date. You also agree that it is the responsibility of the ordering practitioner that their client is made aware of any relevant conditions to the FunctionalDX test. *

Wholesale order? (Internal use only. Not for practitioner use.) Yes No

Clinic Name (optional)

Practitioner Name (optional)

Please note it is the responsibility of the ordering practitioner that their client is made aware of any relevant conditions to the FunctionalDX test.

Important Notice to Practitioners

Please advise your patient that they must ensure their requisition form is printed, completed and signed, and returned inside the FDX kits box to avoid incurring a £30 administration fee, which will require settling before results are released.

A requisition form is sent to both your email address and to your patient’s stated email address to ensure compliance.

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Checkout – Additional Information

Additional Fields

Important Notice to Practitioners

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Additional Fields

Important Notice to Practitioners