Physician Online Order Form

Our Tests
How to Order
Healthcare Professionals
About Us

Our Tests
How to Order
Healthcare Professionals
About Us

Physician Online Order Form

Please use this form to order testing for your patient. This form is intended for one-time use. CirrusDx WILL NOT use this information for sales or marketing purposes.

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

Does your patient live in the state of New York? (Currently we are unable to accept samples from patients residing in NY State.)

Name of insurance plan (or type "n/a" if patient is paying out of pocket)

Policy number (or type "n/a" if patient is paying out of pocket)

Group number (or type "n/a" if patient is paying out of pocket)

Name of policy holder (or type "n/a" if patient is paying out of pocket)

Date of birth

Patient relation to policy holder

self spouse child

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

Current medications

Name of practice

Practice Address

Practice email

Phone number

Fax number

Ordering physician information

Preferred report method

Date signed

Signature

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