About
What We Do
Pharmacogenetics
Comprehensive Medication Management
Proactive Approach
Clinical Impact Assessment
For Patients
How We Can Help
Order Your Test
Medical Professionals
Managing Risk
Clinical Support
Adverse Drug Events
Prescribing Protocol
Order Test Kits
FAQs
Contact Us
Log In
About
What We Do
Pharmacogenetics
Comprehensive Medication Management
Proactive Approach
Clinical Impact Assessment
For Patients
How We Can Help
Order Your Test
Medical Professionals
Managing Risk
Clinical Support
Adverse Drug Events
Prescribing Protocol
Order Test Kits
FAQs
Contact Us
Log In
Patient Name
*
Your Name
First Name
Last Name
Date of Birth
*
Your Date of Birth
MM
DD
YYYY
Your Phone Number
*
What Number Can We Reach You At?
(###)
###
####
Email Address
*
Your Email Address
Address
*
Your Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient History Questions
Please Tell us A Little About Yourself
How Many Medications Do You Take?
*
0 - 2
3 - 6
7 +
Does More Than One Physician Prescribe Medication for You?
*
Yes
No
Are Your Medications Helping You?
*
Yes
No
Are You 60 Years Old or Older?
*
Yes
No
Have You Ever Experienced an Adverse Reaction to a Medication That Caused You to be Hospitalized?
*
Yes
No
Have You Been Admitted to a Hospital in The Past 30 Days?
*
Yes
No
Thank you!
