HCA Home Collection Request Form - CirrusDx

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Our Tests
How to Order
Healthcare Professionals
About Us

Clinician Request for Home Collection

Please use this form to order testing for your patient.

Monday-Friday
8:00AM-9:00PM ET
Phone: 240.813.8801
Fax: 240.238.9408

Report inquiries:
reports@cirrusdx.com

Billing questions:
billing@cirrusdx.com

Patient first name

Patient last name

Patient date of birth

Patient phone number

Patient sex

Patient address

City

State

Zip

Test(s) ordered

UTIP™ + polyMIC™ (identification + antibiotic susceptibility) UTIP™ (identification only) UTIP™ + polyMIC™ + UA (identification + antibiotic susceptibility + urinalysis) STIP™ (sexually transmitted infection panel) AVIP™ + polyMIC™ (aerobic vaginitis identification + antibiotic susceptibility) AVIP™ (aerobic vaginitis identification only) BV/CV (bacterial vaginosis/candida vaginitis) SARS-CoV-2 Influenza A + Influenza B + RSV Influenza A + Influenza B + RSV + SARS-CoV-2

ICD 10 Code

Ordering clinician information

Date signed

Clinician Signature

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